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HomeMy WebLinkAboutBuilding Permit #800-2017 - 95 OLYMPIC LANE 2/23/2017Permit NO: Date LOCATI c✓ Q\ r r BUILDINGPERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION- Ptl Date Received _;4-93-o-10/7 °,,; +` 'ANT: Applicant must complete all items on this IUmpj PROPERTY OWNER M MAP NO: PARCEL: Print ZONING DISTRICT: Historic District yes no Machine Shop Villaae ves no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building tkOne family ❑ Addition ❑ Two or more family 0 Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 11 Others: ❑ Demolition Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands 0 Watershed District ❑ Water/Sewer _0ov01,-__ 6 %;�rvcw,n a_a)04(z� OWNER: Name: Address: `'l' _ CONTRACTOR Nae: Identification Please Type or Print Clearly) ./I Phone: q7R-7_6�-E ( I J�m O tc rvw ►c . Ln - No,M, Hmkovtr, rnA 0 tN S Address: Supervisor's Construction License: ° Exp CS- O��I b31 Home Improvement License: , Exp �� 97 -'� -/fps Date: b4 ZCt Date: /O/�a117 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST ASED ON $125.00 PER S.F. Total Project Co t: $ ©, Soo FEE: $ Check No.: Receipt No.: �S10 � NOTE: Persons contracting with unrevois0red contractors do not have access to, the euarantufund ignature of Agent/Own 3 1� e ✓• TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page Phot FR' _ Pant 1Yegara®Id Structu[ei yes MAP1N®?, ��.� PARCELS ,,GDDISTRI T istori®istrct yews no) l IM An' TYPE vesl �no) TYPE OF IMPROVEMENT PROPOSED USE AO CONTRAC�T,RName�� Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition 0 Other !MPX15 r®U�ll9e+l�14rx 1 1 Flootlpla' njTM��Wetlantls}� `®1Natershetl Dstrict�� 3D�13wt.4 i, '❑Water�Sewer.,;`.ti, a ___, T F� '�'� ` DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: AddrPss.: ARCHITECT/ENGINE AO CONTRAC�T,RName�� SupervisorsaConstructlon'Li IHorne Irnp.�ovement License ::h {� � n� �i 'i ♦fir � �.£`S � [-m'*— tic.-•LZ- EXp. iDate. a,:.t �,_,... �, __ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/.Owner _Signature, of .contractor .. _- Plans Submitted 11= Plans Waived 11 Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE -OF .SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBody Art ❑ ... .Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ -❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature 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 DPW Tow Engineer: Signature: Located 384 Osgood Street FIRE DEPA�TMeI�T -Temp Dumpster on site yes no Located at'124 Main Street Fire Departmerit signaturd1date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions _ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine NOT1=5 and UA I A — (For department use 0 Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department Tine fol[owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ' ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 040TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) A. ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products TOTE: 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; app?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be- submAted with the building application Doc: Doc.Bubding Permit Revised 2012 Location 9 o L 404 01 ['%V• No. ha0 • Kofi Check# !0�,i .� 1 '65 Date a';3- A-0/7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 41NO Foundation Permit Fee $ Other Permit Fee $ 4 TOTAL V . Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 405500.00 m $ - $ 486.00 Plumbing Fee $ 60.75 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.75 Total fees collected $ 707.50 95 Olympic Lane 800-2017 on 2/23/2017 two bathrooms remodel v N a C � N 0 -0 O CD � p O-0 0)2) x • = �o D cam• UTT' '0 O <o v� CL cr � O � �D Q O N• COS' C � v U) O 0 z O 70 7 C K7- 9 9 m �v g cn O O z 0 CD N 0 5' co O CD O 0 E CD3 o��o � __ y <• CD 0 N c0.CL CD 0 00 m rtarL r o•0:�., cn -4 0 a"a: S- - cn :51 W-10. c1n) m n' O y 0 -1 C CD CD 2 a� A 5' 0 0 CL o o 0 COD � cD `D - :,! o�o:� .c 0 to 2 00N b -hU)� o � s = rt V:� Dm 4 a t n C 0 L :J6 o = < CD �cn 2)� CL :• CD CD3 M 0 * CD c rt o c0 � o 0 C CD : CD p CO) rt t CD S CD Q1 OVA a X- � O i rD r -r Z O W O 7 O cm S 7 n� < N O = S O � S _S 7 (D G O OQ S O � O_ N N �. n N O Q \ 7C M :0 v m D m Z D y Z �' -nI O m m n nD '' m 0 M C w Z m 0 p m C ° Z L LA 'O m 3 n s : W 0 0 O m D < o = - C m -h 0 cr U) MO CLCD 0 0 CLC) ;ar 3 y� Z o = N --I v y �; �• o. CD CD n'N C -1 _ N =• CD C (D 2 �• 0 n ^ O �' Q .•t Era) O O '' n W N CD /� _S O V/ O c. N QsN Cl)r M. O0� a _ :• (Q .O n Mo �1 = :Z ir � `� ;o CL ��< Aft cr _C CD �., CD `` cD CD CD O U)CD rt 0�0:4 i 0 CL CD rt� 0 U' b �CO) 0o:4 o v CD fb U) CDr' Cl)��=� O �, O 70 c > C CD n m Z CD =�► O m �• CD O C �. n� 4 N 77 m � N l m - Z o W (� '-� m v M D Z� '{ T :;D OM QQ S > _y z T N C n m O dQ S m m D LA O O QQ n- C C p0 z LA rn O � s 7 m o S O Q v z O m n N -<n 3 0 Q \ n T 3 W O v O m = 0 0 Chuck Schuler 774-248-4451 Anthony Licata 603-765-7020 Date: Owner's Name: Address: Project Site: Project Type: Project Number: Building 2 Plan, LLC 153 Wood Street Hopkinton, MA 0148 www.building2plan.com FIXEDOMM AGREEMENT FebrAlbry 9, 2017 Matthew & Michelle Verminski 95 Olympic Lane North Andover, MA 01845 95 Olympic Lane, N. Andover, MA Tvi% Bathroom Remodels its Ono] MASS CS#74036 MASS H.I.C.#161236 I. PARTIES This contract (hereinafter referred to as "Agreement") is made and entered into on this 9th day of February. 2017, with Maj& & Michelle Verminski (hereinafter referred to as "Owner"); and Building 2 Plan LLC, (hereinafter referred to as "Contractor"). In consideration of the mutual promises, herein, Contractor agrees to perform the following work: g. GENERAL SCOPE OF WORK DESCRIPTION: JOB -SITE PROTEC'nON AND DUST CONTROL: Cover all floors in work areas with drop cloths and/or other materials during duration of work, where required as necessary. Erect temporary dust control curtains at certain intervals. Sweep and vacuum to minimize dust. PLEASE NOTE: SoM6, plaster dust will inevitably escape past our control measures. We make every effort to minimize dust with barriers, vacuuming eta. However we will not be held responsible for dusting every surface of your home. Dust should be expected. Some floor protection may be in place for duration of job and removed when Contractor sees fits. PERMITS: Obtain all permits and schedule inspections, permit fees are additional DEMOLITION: Demo & disposal two bathrooms & master bedroom closet Exposing down to frame as per plan Disposal includes (1) 30 yard containers Demo to include the following; walls, cabinetry, trim, doors flooring & the FRAMING: Frame new walls as per plans meeting MA state code APPLIANCE VENTING: Vent (2) bath fans to outside as per MA state code WINDOWS: Install (1) double hung vinyl window in master bath PLUMBING: Relocate existing to new fixture placement per fixtures plan Install 1 shower head with 1 handheld shower with diverter valve Install (1) air tub in main bath Install (4) lav's with faucet Install (2) water closets Install owner supplied fixtures pt finish ELECTRICAL: Provide new wiring & switches in both baths to meet MA state code Supply & install (2) Panasonic bath fan light combo Wire & install (4) owner supplied sconces over vanities in master & main bath Supply & install up to 8 recessed LED 5"/6" white trim Supply & install materials needed for one air tub Provide electricity for under floor warming mat in both baths Supply & install (1) ceiling fans in master bedroom Supply & install (4) recessed lights in master bedroom Replace 5 recessed lights in upstairs hall (light bulbs currently LED bulbs) Replace outlets & receptacles in master bedroom & large bedroom (Emma's room) Remove lighting structure from large bedroom (Emma's room) Install owner supplied light fixture in large bedroom (Emma's room) All switches & outlets to be white "Decora" All light fixtures to be supplied by owner INSULATION: FA N/A PLASTER: Install W blueboard on all open walls and patching where needed Apply skim coat plaster and sand smooth CABINETS & VANITIES: Install owner supplied cabinets, vanities & related trim as per plan COUNTERTOPS: Supplied & installed by others TRIM & DOORS: Supply & install new baseboard, door and window casing matching existing as per plan Supply & install (2) pre hung door & (1) pocket door TILE: Install owner supplied the PAINTING: Apply (2) coats of Sherwin-Williams in master bedroom & bathrooms (color to TBD) Apply (1) coat of Sherwin-Williams to kitchen walls & trims MISCELLANEOUS: Install owner supplied towel bars & mirrors SHOWER GLASS: Install frameless glass enclosures with rolling hardware in (1) bathroom DAILY CLEAN-UP: Dispose of all waste generated by job. Clean up and leave job site in a clean "broom swept" manner. ADDITIONAL SCOPE OF WORK PAGES ATTACHED: No LUMP SUM PRICE FOR ALL WORK ABOVE: $40,500.00 III. GENERAL CONDITIONS FOR THE AGREEMENT ABOVE A. EXCLUSIONS This Agreement does not include labor and/or materials for the following work at this time: 1. STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of Work" section above, this Agreement does not include labor or materials for the following work: Plans, legal fees, engineering fees, or governmental permits and fees of any kind. 91 Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA). Custom milling of any wood for use in project. Moving Owner's property around the site. Labor or materials required to repair or replace any Owner -supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by Owner, which are damaged during construction. Surveying that may be required to establish accurate property boundaries for setback purposes (fences and old stakes may not be located on actual property lines). Final construction cleaning (Contractor will leave site in "broom swept" condition). Landscaping and irrigation, paving, or street work of any kind. Temporary sanitation, power, or fencing. Removal of soils under house in order to obtain 18 inches (or code -required height) of clear space between bottom of joists and soil. Removal of filled ground or rock or any other materials not removable by ordinary hand tools (unless heavy equipment is specified in Scope of Work section above), correction of existing out -of -plumb or out -of -level conditions in existing structure. Correction of concealed substandard framing. Rerouting/removal of vents, pipes, ducts, structural members, wiring or conduits, steel mesh, which may be discovered in the removal of walls or the cutting of openings in walls. Removal and replacement of existing rot or insect infestation. Failure of surrounding part of existing structure, despite Contractor's good faith efforts to minimize damage, such as plaster or drywall cracking and popped nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by loosened rust within pipes; construction of a continuously level foundation around structure (if lot is sloped more than 6 inches from front to back or side to side, Contractor will step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Public or private utility connection fees. Repair of damage to roadways, driveways, or sidewalks that could occur when construction equipment and vehicles are being used in the normal course of construction. B. ADDITIONAL AND/ OR JOB SPECIFIC EXCLUSIONS: Moving and/or disposing of Owner's property. Snow removal for job site access by others. Pet containment & safety by others. Permit fees. ALLOWANCES: C. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION Commence work, late February 2017. Construction time through substantial completion: Approximately 5-6 weeks, not including delays and adjustments for delays caused by: inclement weather, additional time required for Change Order work, and other delays unavoidable or beyond the control of the Contractor. Start date is contingent upon issuance of building permit. D. CHANGE ORDERS: CONCEALED CONDITIONS AND ADDITIONAL WORK 1. CONCEALED CONDITIONS: This Agreement is based solely on the observations Contractor was able to make with the structure in its current condition at the time this Agreement was bid. If additional concealed conditions are discovered once work has commenced which were not visible at the time this proposal was bid, Contractor will stop 4 work and point out these unforeseen concealed conditions to Owner so that Owner and Contractor can execute a Change Order for any Additional Work. 2. DEVIATION FROM SCOPE OF WORK: Any alteration or deviation from the Scope of Work referred to in this Agreement involving extra costs of materials or labor (including any overage on ALLOWANCE work and any changes in the Scope of Work required by governmental plan checkers or field building inspectors) will be executed upon a written Change Order issued by Contractor and should be signed by Contractor and Owner prior to the commencement of Additional Work by the Contractor. Contractor to supervise, coordinate, and charge 25% profit and overhead on Owner's separate Subcontractors who are working on site at same time as Contractor. Contractor's profit and overhead, and any supervisory labor will not be credited back to Owner with any deductive Change Orders (work deleted from Agreement by Owner). E. PAYMENT SCHEDULE AND PAYMENT TERMS - TBD & NUMBER OF PAYMENTS MAY VARY BASED ON OWNER'S FINAL DECISION 1. PAYMENT SCHEDULE: PAYMENTS DUE UPON SUBSTANTIAL COMPLETION OF THE FOLLOWING JOB PHASES. DUE TO THE DYNAMIC NATURE OF RENOVATING, PAYMENTS MAY NOT ALWAYS FALL IN THE ORDER AS THEY APPEAR BELOW. 1 $4,000.00 Due upon signing of contract 2 $8,000.00 Materials & Labor Deposit due one week prior to start 3 $2,000.00 Completion of demo & framing 4 $8,000.00 Completion of rough electrical & plumbing 5 $2,000.00 Completion of plaster 6 $5,000.00 Completion of the 7 ,2,000.00 Installation of trim & vanities 8 $2,000.00 Completion of painting 9 $6,500.00 Completion of electrical & plumbing 10 $1,000.00 Punch list PAYMENT SCHEDULE TOTAL $40,500.00 2. PAYMENT OF CHANGE ORDERS: Payment for each Change Order is due when the Change Order work is authorized by owner and Contractor submits invoice. 3. ADDITIONAL PAYMENTS FOR ALLOWANCE WORK AND RELATED CREDITS: Payment for work designated in the Agreement as ALLOWANCE work has been initially factored into the Lump Sum Price and Payment Schedule set forth in this Agreement. If the actual cost of the ALLOWANCE work exceeds the line item ALLOWANCE amount in the Agreement, the difference between the cost and the line item ALLOWANCE amount 5 stated in the Agreement will be written up by Contractor as a Change Order subject to Contractor's profit and overhead at the rate of 25%. If the cost of the ALLOWANCE work is less than the ALLOWANCE line item amount listed in the Agreement, a credit will be issued to Owner after all billings related to this particular line item ALLOWANCE work have been received by Contractor. This credit will be applied toward the final payment owing under the Agreement. Contractor profit and overhead and any supervisory labor will not be credited back to Owner for ALLOWANCE work. F. WARRANTY Contractor provides a limited warranty on all Contractor- and Subcontractor -supplied labor and materials used in this project for a period of one year following substantial completion of all work. No warranty is provided by Contractor on any materials furnished by the Owner for installation. No warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor within the dwelling (including any warranty that existing/used materials will not be damaged during the removal and reinstallation process). One year after substantial completion of the project, the Owner's sole remedy (for materials and labor) on all materials that are covered by a manufacturer's warranty is strictly with the manufacturer, not with the Contractor. Repair of the following items is specifically excluded from Contractor's warranty: Damages resulting from lack of Owner maintenance; damages resulting from Owner abuse or ordinary wear and tear; deviations that arise such as the minor cracking of concrete, stucco and plaster; minor stress fractures in drywall due to the curing of lumber; warping and deflection of wood; shrinking/cracking of grouts and caulking; fading of paints and finishes exposed to sunlight. THE EXPRESS WARRANTIES CONTAINED HEREIN ARE IN LIEU OF ALL OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING ANY WARRANTIES OF MERCHANTABILITY, HABITABILITY, OR FITNESS FOR A PARTICULAR USE OR PURPOSE. THIS LIMITED WARRANTY EXCLUDES CONSEQUENTIAL AND INCIDENTAL DAMAGES AND LIMITS THE DURATION OF IMPLIED WARRANTIES TO THE FULLEST EXTENT PERMISSIBLE UNDER STATE AND FEDERAL LAW. G. WORK STOPPAGE, TERMINATION OF CONTRACT FOR DEFAULT, AND INTEREST 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 in this Agreement, or if Owner repeatedly fails or refuses to furnish Contractor with access to the job site and/or product selections or information necessary for the advancement of Contractor's work. Simultaneous with stopping work on the project, the Contractor must give Owner written notice of the nature of Owner's default and must also give the Owner a 14 -day period in which to cure this default. If work is stopped due to any of the above reasons (or for any other material breach of contract by Owner) for a period of 14 days, and the Owner has failed to take significant steps to cure his default, then Contractor may, without prejudicing any other remedies Contractor may have, give written notice of termination of the Agreement to Owner and demand payment for all completed work and materials ordered through the date of work stoppage, and any other loss sustained by Contractor, including Contractor's Profit and Overhead at the rate of 25% on the balance of the incomplete work under the Agreement. Thereafter, Contractor is relieved from all other contractual duties, including all Punch List and warranty work. D H. DISPUTE RESOLUTION AND ATTORNEY'S FEES Any controversy or claim arising out of or related to this Agreement involving an amount of less than $5,000 (or the maximum limit of the court) must be heard in the Small Claims Division of the Municipal Court in the county where the Contractor's office is located. Any controversy or claim arising out of or related to this Agreement which is over the dollar limit of the Small Claims Court must be settled by binding arbitration administered by the American Arbitration Association in accordance with the Construction Industry Arbitration Rules. Judgment upon the award may be entered in any Court having jurisdiction thereof. The prevailing party in any legal proceeding related to this Agreement shall be entitled to payment of reasonable attorney's fees, costs, and expenses. 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 SUCH DISPUTE TO PRIVATE AeBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE CONSUMER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION PROVIDED IN MGL.142A. NTRACTOR'S SIGNATURE DATE WNER'S SIGNAT RE D E NOTICE: THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO AGREEMENT OF THE PARTIES ALTERNATE DISPUTE RESOLUTION INITIATED BY CONTRACTOR. THE OWNER MAY 1141TIATE ALTERNATE DISPUTE RESOLUTION EVEN WHERE THIS SECTION IS NOT SIGNED BY THE PARTIES. .V I. EXPIRATION OF THIS AGREEMENT This Agreement will expire 30 days after the date at the top of page one of this Agreement if not first accepted in writing by Owner. J. ENTIRE AGREEMENT 7 o This Agreement represents and contains the entire agreement between the parties. Prior discussions or verbal representations by the parties that are not contained in this Agreement are not a part of this Agreement. ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE REGISTERED AND ANY INQUIRIES TO REGISTRATION OF SAME SHOULD BE DIRECTED TO: REGISTRATION DIVISION, PROGRAM COORDINATOR ONE ASHBURTON PLACE, ROOM 1301 BOSTON, MA 02108 617-727-3200 X25239 DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES! J. ADDITIONAL LEGAL NOTICES REQUIRED BY STATE OR FEDERAL LAW See page(s) attached: Yes X No K. ADDITIONAL TERMS AND CONDITIONS See page(s) attached: Yes _ZC_No I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. CONT CTOR S SIGNATURE DATE f CU/ 7//7 OWNER'S SIGNATURE DOE 9 VI .� P ! I I - � P I ! i The Commonwealth of Hassachusetis _ Department OfIndustrialAccidefits t X Congress Stred., Suite 100 2 = d Boston, MA 02114-2017 www mass.govIdia • 'QQ'c3�kers' CompensaiioEn �auc�e � � � B�� �.�.��O s ira.cxansl�'lumbers. TO •PTaacP:'Print 7 IzcaIlt �Ox'Z[L'a Lxuu aiion/lndividual): '3 lA l L 12 ir! �� %� I✓ Name (Business/Ozgarii� . Address,/ S-3 f )000 City/State/Zip:_ Axe you an employer? 'c�►�l�i r�i �N eck the appropriate box: D #: ( � 1.❑ 'am a employer with employees (fun and/or pari time). 2_❑ I am a sole proprietor or partnuslnp andhave no employees d,Forking forme in any capacity. JNoworkers' comp. insurance required.] 3.[] I am ahomumner doing all work mysel£ rgo workers' comp. i�rancerequired ] t 4.Q I am ahomeowner andwM be bidug contractorsto conductall work onmy property. Ivrill ensLrctii all con ractbrs eitherhave workers' compensation insurance or are sole <_:. proprietors withno employees. 5.[-1I am a general conaacfor and I have h¢edthe snb-co]]tractors listed onthe attached sheet These sub-contaators have employees andhave workers' comp. insurance. (, eareacorporation.andit' ,offieemhave exeroisedtheirnightof•exemptionperMGLo- jr a no empld'&. [No worker' comp. insurance.required.] yq s_ Type of project (xequireci); 7. [1 Nd--Wdonstru'ciion 8. gTkemodelhik 9. ❑ Demolition. 10 ❑ Building addition 11.[] EleG' tical repairs or. additions 12. [l-Plumbuxg repairs or additions 13•.nR06fr4airs ?4.n Other 152, §i(4), andwe av — Any applicamthat chda bbx#1 —.1 also fill o e section below �d gienhire otdside crs'oo tr tors must sabmii�aneW affidavit indicating such Homeowners wha submit this affidavit indicat mg Y the name of the sub -contractors and state whether or notthose entities have ?Contractors that checkihis Boxrimst aitached'an additional sheetshowing employees. Ifthe sub -contractors have employees, they est provide their workers' comp- Policy nrunber an em to ertlZatisproviL�in9voykew compeYL, adon insuPancef07" M 2772prot�iepolicy aradjo�rszte y2eS. Below zs X acre p .Y information. Xnsurance Company Policy # or Self -in. Lic. #: ExpirationWe' City/State/Zip: Job Site Address: e showing tine policy number and expiration date). Attach a copy of the workers' compensation- Policy declaration Page Failure to secure coverage as required under MGL c. es2xn §ih2e £ rm Q£ O O laid a fine o£np to $250.00 a and/or one-year imprisonment, as well as civil p enaltt RK 61 day against the violator. A copy of this statement may be forwarded to the Of6.ce of Investigations of the DTA for insurance aeauuuvr- i3 X d -o Iiereb c �y =d triepain � ciper�alties ofper ury ilial the inforrac on pro �'� y % I : J: /. _ nate 7 r Q 07 Official zase only Do)toi•rvrite in Mis area, to he co1r�pleterl by city o� toxvrz ofjccial • • Permit/License # city or TOwn-, Issuing Authoxdty (circle one):' ector 5. Plamhing Tmspector 1. Board of Ifealth 2. Building Department3. CityjTovvn Clerk 4. Elecfarzcal Xnsp 6. Other Phone #: Contact P Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eanployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is' d'efiued as "an in.dividug partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enferprhe, and including the legal representatives of a deceased employer, or the receivet'or trustde of an individual, partnership, association, or other legal entity, employing emplbyees. , However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwellijig 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 applicantwhd has not pro'duced-acceptable evidence of compliance with the insurance coverage requiired" Additionally, MGL chapter 152, §25CM 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 withthe 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 sirb=coniractor(s)name(s), addresses) andphonenumber(s) along with theircerocate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. Han LLC or LLP does have employees, a policy is required. Be advised thatthis affidavit may be submitted to the Department of Industrial Accidents for comm oration 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 De' artment of IndustrialAccidenis. should you have any questions regarding the law or if you are required to obtain a workers' compensatiori 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 atthe bottom of the affidavit for you to fiH out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to Min the permit/license number which will be used as a reference number. In addition, an applicant thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (i_f'necessary) and under "Job Site Address" the applicant should write •"all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where ahome owner or citizen is obtaining alicense or permit not related to any business or commercial venture (i.e. a dog license or p ermit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114.2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.S,SAFE Fax # 617-727-7749 Revised 02-23-15 www.naass.gov/dia ACOR:® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 2/21/17 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 Hutchins & Threatt Insurance Whitehall/Girard Insurance Age 488 Boston Post Road E CONTACT AMY MOON PHONE FAX (508) 460-0800 AA No: (508) 460-0803 E-MAIL : amymOOn@htlnsure.COm BMA0024088 Marlboro, MA 01752-360 INSURE S AFFORDING COVERAGE NAIC# INSURER A: SAFETY INS CO INSURED INSURER13:SafetV Insurance BUILDING 2 PLAN LLC c\o Charles Schuler 153 Wood St Hopkinton, MA 01748 INSURER C: 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 OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MIDDN POLICY EXP MM/DDIYYYY LIMITS B GENERAL LIABILITY }; COMMERCIALGENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR Y Y BMA0024088 8/20/16 8/20/17 EACH OCCURRENCE $ 1,000,000 PRMISETORENTED $ 100,000 MED EXP (Anyone Person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER POLICY PRO- LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS _ AUTOS CONS IN ED SINGL E L IM IT _.Tr accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ eraccident $ B X I UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CMU0005826 8/20/16 8/20/17 EACH OCCURRENCE $ AGGREGATE $ 1,000,000 DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBE2 EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A WC STATU- OTH- E.L. EACH AGO DENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is reqs red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISbNS. BUILDING DEPT 120 MAIN ST AUTHORIZED REPRESENTATIVE NORTH ANDOVER, MA 01845 AMY MOON © 1988 2010 ACO RD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mail: Elo .j