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Miscellaneous - 210 FARNUM STREET 4/30/2018
N CUSTARD INSURANCE ADJUSTERS 3135 Avalon Ridge PI Suite 200 Norcross, GA 30071 3/10/2015 CITY/TOWN BUILDING COMMISSIONER Gerald Brown Inspector of Buildings 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Claim Number: Policy Number: Company Name: Date of Loss: Insured: Property Location: 033552454 69918400002 Arbella Mutual Insurance Company 2/25/2015 Neil Thurber 210 Farnum St North Andover, MA 01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,. to be applicable. If any notice under Massachusetts General Lav, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Arbella Mutual Insurance Company CC: City/Town Fire Dept, City/Town Health Dept Date ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING A This certifies that .W44/7.w .. .... has permission to perform ........ ...... ...... ....... 4-. wiringin the building of ........ i ..................................................................................................... at ......2 ......... ............................................ A..... .�..... 1 . -�..�... ..... ........... .A* orth Andover, Ma...s..s... Fee ........................ Lic. N0,3 D... .... ........ARICALNSPWCT ELE Check# . A Commonwealth of /Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. / 1 Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ` i 1-01, S City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) l o �4tr+n .rte Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 91 No ❑ (Check Appropriate Box) Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: '� ; �;,��, ?�13 ,, 'a, bAs,e,,yLJ +- Completion of the_ following table may be waived by the Inspector of Wires. No. of Recessed Luminaires tj No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets (.p No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number ' ' ' Tons ' KW ."".'".. "' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value f El trial Work: 0 (When required by municipal policy.) Work to Start: lZe 15 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no,permit for the performance of electrical work may issue unless. the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. ". CHECK ONE: INSUIRANCE V BOND ❑ OTHER ❑ (Specify:) 11 I certify, under the pains and penalties of perjury, that the information on this application is true anti complete. FIRM NAME:. LIC. NO.: Licensee: �c�s� c s w"n Signature LIC. NO.: i37 -7 0 3 (If applicable, ente,rrer�"exempt" in t*�i ense number line) Bus. Tel. No. • NT Address: K(,.,i 1� 1/���^ �cA, Oto b30 "1 Alt. Tel. No.•6,03-930'2513 *Per M.G.L c. 147, s. 57- 1, security work requires Department of Public Safety "S" License: _ . Lic. •No. + OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance: with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written �— application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass F?] Failed ❑' _ Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH MSP CTION: Pass 0 Failed 1fl Re- Inspection Required ($.) ❑ Inspectors Comm"ns Inspectors Signature. Date: FINAL INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com nts: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofMassachusetts Department oflndustrial Accidents Office Oflnvestigations 600 Washington. Street ..Boston, MA 02111 www.mass govIdla Workers' Compensation Insurance Affidavit: Builders/Contracfors/Mc AwDHcant Information Name (Business/Orgai&aiion&dividual): Address: v `Phoe: 6aCity/State/Zip:Wi�d 1�73 . Are you an employer? Check the appropriate box: Type of project (required): 1. Q 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. [] Now construction f employees (fall and/or part-time).* have hired the sub -contractors 2). 1 am a sole proprietor or partner- listed on the attached sheet t 7. 10 Remodeling ship and'have no employees These sub -contractors have 8. [l Demolition working for me in. any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. ❑ We are a corpora] on and its 10.] Electrical repairs or additions required.] officers have exercised.their _3.E1 I am a homeowner lining all work right of exemption per MGL 11. [] Plumbing repairs or additions myself. [No workerscomp. c. 152, §1(4), andwehaveno 12.❑ Roofrepairs insuran.cerequired.) employees. [No workers' 13.❑ Other comp. insurance required.] xAny applicant that checks box#I must also fillout the section beldw showing their workers' compensation policy information. i Homeowners who sabmft this affidavit indicatingthey are doing allworK and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below zs the policy and joh site information. Insurance Company Policy ## or Self ins..Lic. #: Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers' compensationpolley declaration page (showing the policy number and expiration date). Failure to secure coverage.as requiredunder Section 25A ofMGL 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 WORT{ 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 lieaeby cert ur�icier the pains and penal ' perjury that the information provided aabovel is thre and correct, - Phone#• Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing.A.uthorRy (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation .for their employees. Pursuazit to this statute, an employee is defined as "...every person k the service of another under any contract of=hire,• express or implied, oral ov written." An employeils defined as "an individual, partnership, association, corporation or other legal entity, or anyiwo ormore of the foregoing engaged in a joint enterprise, and including the legal representatives of a: deceased employer, or the receiver or'iu tee of au 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 ofthe dwelling house of another who employs persons to do maintenance, construction orrepair work ou such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to bean 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 arty 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 b con presented to the contracting authority." Applicants Please fillout the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-confractor(s) name(s), address(es) andphonenumber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for thepermit 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 thatthe 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 thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town):' .A: copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit -lion file for future Hermits or licenses..A, new affidavit must be filled out each year. Where ahomeowner or citizen is obtaining alicense orpermitnotrelated to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitate to give us a call. The Department's address, telephone and fax number: Tho CQmmouw.oa1t1xofS�/► ssachu etEs L7opaftent of3h4wWal.A,ccidonts Qfiee 41:1RVesiigati0us 60 Wash ora. Shred Boston,. MA 02111 Tel # 617-7.27 49QQ QA 406 ox 1-$77•:t1I S.FE Revised 5-26-05 Fax # 617-727'7749 �.x�ass,govfc�°a m El 4 I ,ANo 2899 Date ........ ...... .:.....-......... r1/ .17 b TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ...........- - .....'.'? ........ :....................... has permission to perform ...:::. C s:. , �. E - -� ............................................................. -%virire ;n the building of .... : �... ? v at ...............................................................-'�-,North A7tdover, Mass. .......... Fee *._: ............. Lic. No r "..%c ..... I . /........ .... .......... $LECTRICAL INSP R Check # i WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TRF09 MONWE4LTHOFh 4Y94QR1SEM Office Use only DEPARTMEVTOFPUBLIC&4FM Permit No. C�-epy7 BOARD OFFMPREVEMONRFa MT10AN527CMR12:00 � Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS 11.ECIRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat lleoj Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) f Owner or Tenant �QIV _ or.n. , T . Owner's Address v Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box) i� Purpose of Building Utility Authorization No. Existing Service Amps�bVolts Overhead Underground M No. of Meters New Service AmpsVolts Overhead Jnderground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 1:1ound No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets .R No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices LocalMunicipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER lr ra=Caer-� Rxm"iDthetagtnattatsdMassa�CoviElLaws Iha%eaarattImbt7dybtstratoePbhymdtd'agCat Oe a�ai;sst#�at�tialec�rivalent YES NO M IhaNtabriltedvaMptoofofsa lotheOBioa YES =NO IfymImedte WYES,pleaseirdic*fttAxofwmaWbydxcimgthe MMANUE �r7 oTHR VCMspe�cy) AVA Lfaz/ 5Vizticri`l)* .1 EsMxftdV"dUmftxalWo& $ WakiDSw bgecfimD.*Regtxsted Rao Final Sigafp nmmze FIRMNAME MNAME c��// ��`J `S' OWNER'S itsiRANCEWANER;lanawatethatftLiw=do not aodivtmysigttke«tihsp=*a otturai%sthistaqmama>t. (Please check one) Owner M Agent Telephone No. PERMIT FEE $ 6Z A Date ......................C7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........j�S�eox,S.S ...... .....S../...�...�...f...S... .... has permission to perform .........4. eo,� wiring in the building of ........ at ...........o9 /� . ../;.i{ ��..4...........� ,..... , North Andover, Mass. ......... / 33 G Fee .'7/ ©' ..... Lic. No. '. / .......... ... 15.......... v . ,. ............. % ELECTRICAL INSPECTOR Check # c� 8069 (_,onvnon�uaalth o���///a�sara3 � ..CJaParlmen� o�Jira �arvGCa� BOARD,OF FIRE PREVENTION REGULATIONS Offici gal Use Only Pen -nit No. (�� Occupancy and Fee Checked [Rev. 1/07] (leave blank) TO- PERFORM ELECTRICAL- WORK APPLICATION FOR PERMIT All wor to be performed in accordance with the Massachusetts Electrical Cod,: (MEC), 527 CMR')2.00 (PLEASE PRINTrNINKORTYPEALLINFORMATION)-: Date: City or Town of: Vi ,N( -J AJef�— To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Q Owner or Tenant G11 a\pc TL,,- TwPOpyy . Telephone No. Owner's Address Is this permit in conjunction with a building permit?Yes ❑ No N] (Check Appropriate Box) Purpose of Building Existing Service _ New Service Amps / Volts Amps / Volts Number of Feeders and Ampacity Utility Authorization Ne. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters atilt Location and Nature of Proposed Electrical Work: �J�• � � � �� t c � o � P-, Ur t p r -t re : �t,art'1 f Cnmnleron of the fnllowinv table may be waived by the Inspector of Wires. No. e'"Recessed Luminaires No. of Ceil: Sus Paddle Fans ( _ P• ) r f I oEa Transformers KVA Tr No. of Luminaire Outlets No. of Hot Tubs A ovec.5TEmergency Pool ❑ ❑_ Generators KVA - Lighting No. of Luminaires Swimming <<r�d. grad. Bat'.ery Units No. of Receptacle Outlets No. of Oil Burners FIRE a.LARMS 1 No. or "L fes No. of Switches No. of Gas Burners o. of etection an ; ;itiatine Devices No. of Ranges _ _ Total No. of Air Cond. Tons No. of Alerting Devices -Self eat um um er_ ons o. of -Contained No. of Waste Disposers Total s - y �' ' Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW SP b _ Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E ivalent No. o. o Water /eaters KW o. o 0.0 Si ns Ballasts Data Wiring: No. of Devices ar E uiv :lent e ecommuntcattons iring: No. Hydromassage BathtubsNo. of Motors Tota: HP No. of Devices'or E uivalent (OTHER: 9 -7 —a ja Attach aaamonar aerarr 1 aesirea, ar a rdq—cu u� .. .•. r� •�• •• -- --- Estimated Value of Electrical Work: S31 J � (When required by. municipal policy.) Work to Start:_ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE; Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 'ZJ BOND ❑ OTHER 0 (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete1-6-3,3 S33 C - FIRM NAME: ,7-' S�-GctrtTN Sc, �l�„ _ —,_ LIC. NO.: Licensee: !( K LL Signatures _'_. LIC. NO.: �5-f (/jopplicable, enter "exe pt" in the licen num er line.) Bus. Tel. No.: Address: � � [? L I NT'Lm fie- /yrs Uh a9 —Alt: Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety, "S" License: Lic. No. .S CG' O G / 9 75 OWNER'S INSURANCE WAIVER: I am aware that the Licensee dt)es -ot have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature _ __ Telephone I` o._ _ hPFRMIT FEE: $ �J r r m z m m ,p co W A A V N W W oca A:l c-a�mc.=s: =: 0 W N T . 0 c NMSr-z bE--<z %0 L. i ,• - 71 ;r =zo o, �'? 0 o z to ((( Vl z to � m K z m r to CD H z .3 .o v o mv� -i —t O o (n 2E V M C) o c�3° z m oN m �; a I c 1 0 00� o -n -n 3 m r`-` C C� s o \\ o cn m c r Drny z 177 (� D to A w m T m M r r m z m m ,p co W A A V N W W oca A:l c-a�mc.=s: =: W N T . 0 c NMSr-z bE--<z %0 L. i ,• - 71 ;r m o, �'? ., Z. in Vl z to � m 67 r ,o -i —t O o (n 2E M S z --i O m m „ 1 C7n 1 z 177 C to M cn n CDD ►� - ��•.Lrl.sa.�.11nen��a11 M L 1 U (n m u moi' m M,Co c N W .. ` CD 1 ni Z N w L o "o v C) A 9 07 3 CL a co a d CL 1 D n 7 n a O 0 f� I r. r X 0 TIF -7 V) n X C ur in fJ� I a�l Z r x c � I'ili;j'sjljll j ( 3 � °nz c y n —� C m odZ C7 � O \ O > m Ln O -n CJ \\ xm -� D p ;a z (D a m .� o N N r- z (n O O' CD N --° -� 0 n C! Co CD C3 �n 3. C/) X CO ^^,, CD rnSLI n O `V (D CL -i O o a o i AN _ ` 1 {Q Location Y-0 No. Date MQRTN TOWN OF NORTH ANDOVER F ,' 9 Certificate of Occupancy $ SSACMUStS� Building/Frame Permit Fee $ Foundation Permit Fee $ - Other Permit Fee $ TOTAL $ Check # �� C2�-s--- 1740 Building Inspector r of TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: —�7 DATE ISSUED: 46 0-2 SIGNATURE: &( Building Com ssioner/I for of Buildings Date SECTION 1- SITE INFORMATION' s' 1.1 Property Address: -2.It� fiH,ItNHA�n Si I I D LU I I L. LJ 1 5 L I I U L. T C J 114 U 111, 1.2 Assessors Map and Parcel Map Number' `` Number: Parcel Number - ' S) . 1.3 Zoning Information: Zoning District Proposed Use Signature Telephone 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft r ` Front Yard Side Yard i Name Print Address for Service: Rear Yard R red Provide RegWred Provided R ' 'red Provided 3.1 Licensed Construction Supervisor: Not Applicable ❑ 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT I I D LU I I L. LJ 1 5 L I I U L. T C J 114 U 111, 2.1 Owner of Record RscHAm S) . Name (Print) Address for Service : Signature Telephone 2.2 Owner of Record: r c i Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number 13 N����` S�' Address N0. t'L�Z''1 G t17 • S Z" I! o y Expiration, Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1 Mv,,L 14 R�- Company Name Registration Number ✓ 33 Hn,,�rA. sr 06.0L.0,0tP Address -t0-1 ��t+� 6` S 1 1 S �% 1 Expiration Date Signature Telephone 0 SECTION 4 - WORKERS COMPENSATION (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 issuance of the building permit. Signed affidavit Attached Yes .......1A' No ....... 0 SECTION 5 Description of Proposed Work check all a llcable New Construction ❑ 1 Existing Building 1< I Repair(s) ❑ 1 Alterations(s) JW I Addition ❑ Accessory Bldg. ❑ I Demolition ,IO I Other 0 Specify Brief Description of Proposed Work: N4w wrJoaw A0o J Li. JUA I SECTION 6 - F.STIMATFn rnNCTAiTfTTnN rncT4Z Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Com leted bpermit applicant 1. Building Z �. �v (a) Building Permit Fee Multiplier 2 Electrical 001) (b) Estimated Total Cost of Construction 3 Plumbing I 606 Building Permit fee (a) x (b) --- 4 Mechanical HVAC O 5 Fire Protection O 6 Total 1+2+3+4+5 pp0 Check Number grn.iavix in vvri'qcn Aulnul "'AILUIN 1V DE I.,VMNLt1hV WULN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> as Owner/Authorized Agent of subject property Hereby authorize My behalf, in all matters relative to work authorized by this building permit application. to act on Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION M%AAPS Y as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief S fA-APNIf Print Name f.lZ y %oy Signature of Owner/Agent Date , NO. OF STORIES Z BASEMENT OR SLAB 13PA&%&Jr SIZE OF FLOOR TIMBERS iST SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION SIZE OF FOOTING MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE SIZE Z y x L u 2 ND ,. . ,4 THICKNESS .X I North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with he provision of MGL c 40 S 54, a condition of Building Permit Number 7AF is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: Hart.izSS WNT. Pd. Im6ftri4 &.-4. (Location of Facility) Signature of rmit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector s A. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 065265 Birthdate: 09/2911968 Expires: 09/2912005 Restricted: 00 SEAN M MURPHY 233 HAVERHILL ST - N READING, MA 01864 Tr. no: 16879 Q V Acting Co*imissloner Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 125482 Expiration: 1/5/2006 Type: DBA Sean M. Murphy Gen. Con. Sean Murphy 233 Haverhill St.„�.u.i N Reading, MA 01864 Administrator The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Afdavit Name Please Print Name: S 66rij n KAp H y Location: J:Oari M4^-% City Igo, *A 0a\1VI./L Phone # I am a homeowner performing all work myself. ® I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City. Phone #: Insurance. Co. Policy # Company name: Address City: Phone #: Insurance Co. _ Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment as _well_as _ctvil,Renatties in.1hefnrm -of -a._STOP WORK ORDFR..and_a fine of _($100.00)_a stay against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 6; 4/1`I/oN Print name S6AY4 MWL?4y Phone# 61-)' S%Z "t16Y Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing 0 Building Dept ❑Check if immediate response is required 0 Licensing Board p Selectman's Office Contact person: Phone #: F, Health Department f -i Other MSEAN M MURPHY GENERAL CONTRACTING 233 HAVERHML STREET NORTH READING, MA 01864 617-512-1104 NQ..... ....... . BURKE RESIDENCE 210 FARNHAM ST. NO. ANDOVER, MA. KITCHEN RENOVATIONS SCOPE OF WORK: REMOVE EXISTING CABINETS, COUNTERTOPS, FLOORING, CEILING BEAMS, DOOR AND WINDOW,ETC. INSTALL NEW SLIDING GLASS DOOR, REMOVE OLD WINDOW AND DOOR. INSTALL NEW WINDOW OVER SINK IN NEW LOCATION. INSTALL NEW CLAPBOARD SIDING TO MATCH EXISTING BUILD SMALL TWO STEP LANDING OUTSIDE NEW DOOR INSTALL NEW TOE KICK HEATER AND REMOVE EXISTING PIECE OF HEAT NEW INTERIOR WALLBOARD, TRIM, INSULATION WHERE NEEDED SUPPLY AND INSTALL NEW CABINETS, GRANITE COUNTERTOPS, SINK AND FAUCET INSTALL NEW BEAD BOARD CEILING SAND AND REFINISH PINE FLOORS INSTALL NEW LIGHTING IN AREA AS WELL AS IN CABINET LIGHTS HOOK-UP ALL APLIANCES PRICE INCLUDES ALL PERMITS, FEES, AND DISPOSAL OF DEBRIS. TOTAL COST OF JOB: $ 27,000.00 m m m x m m v y C � � d C40 CM) � O CD a Z y 0. O �. C13 ? O C. y 0 M v CD CDCL O cr d co CD o CD mm S C CD y CL CD y �• O to C n O w O �to0Q ao no y 0 CD CD yC!CL 3 T Z �-o w -- CL 0 a go rn Er �o m O y N Cl*?:: m = O CD m �. o O OZy,C N M'� W a OO �y %. 2L a p C m O o h 0to CLg �..�y y Ot y N d I : Q y CL Z C m V J H � CA _ W �° CA: t x � OWN` o m ' :� C ➢ i S � • � pix � ��,,,�. _ CA Jom �*. O 0 _� c C',� 0 cncn O Z w w C C17 Ix w Pi C m w n z G G °a c ti O CL O '•7 omi 0 9 0 PMK LAO .a RY NOR7q O 9 s i a Date.4k/(//- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUS� This certifies that ........ n . . has permission to perform plumbing in the buildings of at �Vlw � � �f�' � .? 1�- ... , North Andover, Mass. /U PLUMBING INSPECTOR 1 Check t1 01 5 � 6x66 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location New rl Renovation ri Type of Occupancy Replacemet . iI FIXTURES 9Iz TION FOR PERMIT TO DO PLUMBIN Date 1—d/ Permit # Amount Plans Submitted Yes No ❑ (Print or type) I I Check one: Certificate Installing Company Name kj- Pl ut-7btkn ici Corp. Address U Partner. N 0-112 Business Telep one / 1 Co. Name of Licensed Plumber:d.ti f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond F1 t Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and lat performed der t Issuedor this application will be in compliance with all pertinent provisions of the Ma ate Plumbi o a a t 2 of the General Laws. own ZOVED (OFFICE USE ONLY l r Type of Plumbing License / Muse=7u-mDeer-- Master tErJoumeyman Date ..... o NORTy pya TOWN OF NORTH ANDOVER �o PERMIT FOR GAS INSTALLATION This certifies that .....G`....... ............... has permission for gas i stalla ion .. �%�(. ........ in the buildings -of .%�!.!`'t! '' . . ��•��• at J. Z�!f 1-1 ! �. /' (, ,North Andover, Mass. Feer / e-.U�! Lic. No. �U,�WX ......................... . A GAS INSPECTOR Check # 0� 4771 MASSACHUSETTS UNIFORM APPLICATON FOPERM TO DO GAS FI rnNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS % Building Locations Q' �� / `j f Permit # Amount $ Owner's Name Newn .Renovation Replacement Plans Submitted ❑ El �f (Print or type) P ! (lU Name 7� Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. 6'_Firm/Co. INS>JRANCE COVERAGE Check one: . I have current liability Insurance policy or it's substantial equivalent. Yes D No ❑ If you n,,ave checked yes, please Indic the type coverage by checking the appropriate box. ❑ Liability insurance policy �e. Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perform under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett ode andte 14 e Gen Laws. City/Town IAPPROVED (OFFICE USE ONLY) gnature of Licensed Plumber Or Gas RT Plumber /0 ®G s Fitter License Number aster ❑ Journeyman � � a w a c U x x U z o z z o a H Gw w w �. 5 w F � � F a col p9 c� O U > Q w H SUB -BA -BASEMENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5 T H. F L O O R 6TH . F L O O R 7TH. FLOOR 8TH. FLOOR (Print or type) P ! (lU Name 7� Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ❑ Corp. ❑ Partner. 6'_Firm/Co. INS>JRANCE COVERAGE Check one: . I have current liability Insurance policy or it's substantial equivalent. Yes D No ❑ If you n,,ave checked yes, please Indic the type coverage by checking the appropriate box. ❑ Liability insurance policy �e. Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perform under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett ode andte 14 e Gen Laws. City/Town IAPPROVED (OFFICE USE ONLY) gnature of Licensed Plumber Or Gas RT Plumber /0 ®G s Fitter License Number aster ❑ Journeyman �2� /.*,7- e_v 344 Date .. ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION • . Tis certifies that..-...... ,�......... has permission for gas installation inil,the buildings of ...................... at ...... North Andover, Mass. Fee. Lic. No ........ GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS a ` � Date Building Location /I C�/�U% Owners Name /�J l� Permit f Amount v New M Renovation F1 Plans Submitted Yes No (Print or type) - /` Check one: Certificate Installing Company Name Corp. Address r� i L ' Lliv Partner. ®V mR -( �/4— 1 Business Telephone g,2P'<imVCo. Name of.Licensed Plumber Insurance Coverage: Indicate Liability insurance policy f insurance coverage by checki Other type of indemnity "o g the appropriate box: ❑ Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and information I have submitted (or best of my knowledge and that all plumbing work andMst*em compliance with all pertinent provisions of the Massac By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumb mg License 4001,5" 1 nse Number Master Agent 'cation are true and accurate to the rs app ication will be in 142 of the General Laws. Journeyman ❑ dp • • .1 I 1 � MONO 0000000OWWWWWOMMM (Print or type) - /` Check one: Certificate Installing Company Name Corp. Address r� i L ' Lliv Partner. ®V mR -( �/4— 1 Business Telephone g,2P'<imVCo. Name of.Licensed Plumber Insurance Coverage: Indicate Liability insurance policy f insurance coverage by checki Other type of indemnity "o g the appropriate box: ❑ Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and information I have submitted (or best of my knowledge and that all plumbing work andMst*em compliance with all pertinent provisions of the Massac By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumb mg License 4001,5" 1 nse Number Master Agent 'cation are true and accurate to the rs app ication will be in 142 of the General Laws. Journeyman ❑ AS -BUILT CHECKLIST LOT NUMBER, STREET NAME _ ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS i� LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX v ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. Y NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED �Jy ,tee Permit No#: V I ` BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1 / Date Received Date Issued: IMPORTANT: Applicant must complete all items on this LOCATION 2, VQ,(- fskl (h S Ci2�� Print,\\ PROPERTY OWNER Print 100 Year Structure yes no MAP PARCEL: 0162 ZONING DISTRICT: Historic District ye no Machine Shop Village y no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family El Industrial ❑ Alteration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other —6-7s- :eptic ❑Well " - F .. D Flood , latn ®Wetlands, p ti Os Waters} ed Distrct erlSewer � t N DESCRIPTION OF WORK TO BE PERFORMED: r-nc P- &r K 1�2Oa I �sz Pcoo( \zv(� OWNER: Name: l• Please Type or Print Clearly )&,,3 e ✓✓ Address: 2/6 Contractor Name: Ney GS ---VL Se -v %'Ce.S Phone: Email: cirk • COM Address: '?.0.'Z&k 9'23 \ o us MF_ Supervisor's Construction License: GS o-7399 t Exp. Date: 14-7116 Home Improvement License: i 29 l -7 7 Exp. Date: -71 int 1 C7 ARCHITECT/ENGINEER Phone:_ Address: Reg. No. Gd a721 FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 100 FEE: $ q Check No.: Receipt No.. I NOTE: Persons contracting with, unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ S11113ing pools ❑ Well ❑ Tobacco Sales ❑ Food packaging/Sales ❑ Private (septic tank, etc. ❑ Pennanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature. COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 4 I Planning Board Decision: Comments k a Conservation Decision: Comments Water & Sewer Connection/Signature Date Driveway Permit ]DPW Town Engineer: Signature: .��.cuvNa�u11G11L�'b Ufe/Qate •x.. h, .. COMME-NTS- ".. _ ..�'.i,"�'�• :7. ��' � � "- Located 384 Osgood Street ars4U 'r on;site:t! yes +s `. '. --t �' ' �,>. �� '.•Ry+?x �+ r}t ' i` r t, wk i rl ..t �` , . _-. .h �, t �5 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of deter location, trust or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1oo-$10oo fine NOTES and DATA — (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 4. Building Permit Application 4. 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 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit 4, Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products 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 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: Building Permit Revised 2014 Location n✓ U �1 No.��� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 4-7 Foundation Permit Fee $� Other Permit Fee $ TOTAL $ Check # (9-17-1 17 Building Inspector < c 0'a c --1 O MU v =_; < rv'n CD�� y• 0 g i e�•P rt . Z 0 _3 ="-aN O, O U! rt CD TI {� S —En�D d .„ in <D W n y O N =• (D C CD 2. O S. 5• � O rt V) n N rt ,a _ CD �� mo CD CL rrn N rt O CI) CCD O 0=0rCD — Cn _ � ~, y DCQ. n C O O x0 D CD v, a z cl)C C � O 0 --1<N O CL C ~y (D �D O CL O C � Q m c� C Q. Z WCD ... r� O CD CD OCD :* .. 0 00 CD _oU) D o Co CD .t U)Co CD cn b �� vCD CD S r,, v 5.0 — _ D CD Z '-0cn CD m� c CD � °• :�} pCL : o O 00 OMMOUN a N X- ref N Z co 1 O c M > T 3 .Z7 O 007 > Z �+ A _T 7 N � O aQ � '° D r- vZi T 7 ;o O 007 W Z to T j S (D O D07 O j N O W v fD N ^ O 2 7C 3 m > C O m z 0 0 O x M 01 n Is Page 1 of 4 Nexus II Carpentry and Construction Design P.O. Box 2823 Woburn, MA 01888 781760 2031 Fax 978 9751263 nexuscaryentrO'baol. com Contract This is a contract between Elizabeth Thurber of 210 Farnum Street, North Andover MA 01845 (Hereafter referred to as the "owners") and Nexus II Services (hereafter referred to as "Nexus") dated January 13'" 2016. GENERAL SCOPE OF WORK DESCRIPTION WE HEREBY SUBMIT SPECIFICATIONS AND CONTRACT FOR: work as stated below to your rear lower roof and fascias Scope of work: General details ♦ Meet with local building official and apply for permits ♦ All work will be in accordance with local building code regulations and will be inspected by local officials prior to continuing with the next phase — Nexus will be responsible for arranging and being available for all inspections ♦ Nexus will contact "Dig Safe" prior to commencing any excavation work for their clearance ♦ All work will be coordinated directly between "owners" and Nexus ♦ Nexus confirms that it is fully licensed, insured and ensures any sub -contractors utilized on this site will have the appropriate insurance coverage ♦ Nexus will be responsible for the safe storage of all its property and any materials to be used on the site ♦ Owner is responsible for removal and return of all items of the house in the areas that will be affected and their safe storage prior to our work commencing SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 2 of 4 ♦ Owner will then be responsible for returning all items to these areas of the home after completion of the scope of work ♦ Remove and trash into Nexus supplied dumpster all trash associated with this project NOTE: appliances are not allowed to be put in dumpsters without additional costs "owners" are responsible for removal from site Scope of Work Roof shingles; ♦ Make application to the Building department for building permit only ♦ Remove from trash all trash associated with this scope of work ♦ Remove and trash existing roof shingles on lower roof only and only at rear of home NOTE: no garage or front of home roof work intended or include ♦ Remove and trash up to 96 sq ft of existing plywood ♦ Furnish and install new exterior grade plywood to replace these areas only ♦ Furnish and install ice and water shield ♦ Furnish and install drip edge ♦ Furnish and install new roof shingles to match as closely as possible to existing roof shingles NOTE: these shingles will not be a perfect match to the existing roof shingles but will be "common shingle" that should be available in the future Fascias and gutters; ♦ Remove and trash existing gutters, downspouts and fascias from the 2nd floor of the rear dormer AND the 1St floor rear area directly below the dormer ♦ Furnish and install Azek/composite fascia boards to existing rafter tails on both the lower and the upper sections ♦ Furnish and install WHITE aluminum gutters to new fascia boards ♦ Furnish and install WHITE aluminum downspouts to these 2 sections only Work not included in this contract Building department fees Engineering or architect costs Permit costs Unseen conditions Painting or staining work — Rubber roof nor any other roof work to the existing 2nd floor dormer Any other work not specifically noted above SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 3 of 4 PERMITS "Nexus" will accept responsibility to obtain the necessary building permits. "Nexus" will act as a GC and work in accordance with fair and reasonable practices, and cooperate fully and under the guidance of the "Owners" and authorized parties. Nexus will pass the cost of the permit directly on to the "Owners" once advised by the Building department. 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 (any Exclusions in this paragraph which have been lined out and initialed by the parties do not apply to this Agreement): 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 "Owners" property around the site. Labor or materials required repairing or replacing any "Owners" - supplied materials. Repair of concealed underground utilities not located on prints or physically staked out by "Owners", 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 ("Nexus" will leave site in "broom swept" condition). Landscaping and irrigation 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. Removal and replacement of existing rot or insect infestation. Construction of a continuously level foundation around structure (if lot is sloped more than 6 inches from front to back or side to side, "Nexus" step the foundation in accordance with the slope of the lot). Exact matching of existing finishes. Repair of damage to roadways, sidewalks, or driveways that could occur when construction equipment and vehicles are being used in the normal course of construction. The "Owner" is to enter into contracts for all of the above-mentioned services and provide direct payment to "Nexus" for all of the services we are to provide. "Nexus" will be responsible for removing all components and all construction materials relevant to the "scope of work" in this contract. The "Owners" have received a copy of the lead hazard information pamphlet informing them of the potential risk of the lead hazard exposure from renovation activity to be performed in the dwelling unit. This was received before the work began and the "owners" are responsible for informing their tenants of all potential hazards. Dumpsters, trailers and signs "Nexus" will provide as included in the cost of this project, a dumpster for the sole purpose of the removal of trash associated with this project. This dumpster should not be used by any persons for any other waste items or for any purpose outside of the specific use under the scope of work, unless authorization is received from "Nexus". Nexus may have on site for part, or the whole of the project, a trailer containing materials and tools belonging to "Nexus". This trailer will be parked in a position agreed to in coordination with the "Owners" and will be covered under the insurances of "Nexus" at all times. "Nexus" will have on site, a sign, with our contact details, in the event that anyone has a need to contact us directly. Photographs "Nexus" reserves the right to, from time to time, take photographs of the contracted work for use in its general marketing or for production on its web site. At no time will "Nexus" share any personal contact details of the "owner" for any photographs that it may use without seeking authorization from the "owner". Warranties All the components supplied by "Nexus" as part of the original order are covered under the warranty exercised by "Nexus" and supported by the vendors. All labor and materials purchased from other suppliers to achieve completion of contract are warranted (1) one year from completion of the construction. Expiration of this Agreement: This Agreement will expire 30 days after the date at the top of page one of this agreement if not accepted in writing by "Owners" and returned to "Nexus" along with the necessary deposits within that time frame. SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT Page 4 of 4 Changes in the Work: During the course of the project, "Owners" may order changes in the work (both additions and deletions). "Nexus" will determine the cost of these changes and the cost of this additional work will be added to "Nexus" profit and overhead. People Authorized to Sign Change Orders: The following people are authorized to sign Change Orders: "Nexus": Mark Gotobed or ed White We" "Client": Elizabeth or Neil Thurber Concealed Conditions: This Agreement is based solely on the observations "Nexus" was able to make with the area 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, "Nexus" will stop work and point out these unforeseen Concealed Conditions to "Owners" so that "Owners" and "Nexus" can execute a Change Order for any Additional Work. Schedule of work It is agreed by both parties that this work will be coordinated with the "Owners" and "Nexus" to be undertaken in various stages to avoid complete disruption of the home environment. "Nexus" will give "Owners" no less than 2 days notice prior to arriving on site for commencement of any of the agreed stages of work to allow "Owners" to prepare. "Owners" commits to have sites identified for construction work available for start at the beginning of the scheduled day so as to avoid any unnecessary delays. Contract Cost and Payment Schedule: Total cost of work description and materials included in the proposal (except materials/work stated) - $8,100.00 (Eight thousand one hundred dollars and zero cents) PAYMENT SCHEDULE 1st Payment due upon signing this contract TOTAL $4,050.00 Final payment due upon completion of scope of work TOTAL $4,050.00 Amount due upon signing this contract - $4, 050.00 I have read and understand, and I agree to, all the terms and conditions contained in the proposal above. Date .............................. "Nexus" Authorization ............................................................ Date/.1f.. /.1? ....... "Client" Authorization ............................... Ii ........... Date ............................... "Client" Authorization ...................................................... SPECIALIZING IN QUALITY FINISH CARPENTRY, REMODELING, SPECIALIST ROOF SYSTEMS, SITE AND PROJECT MANAGEMENT The Commonwealth of Massa,ch�csetis Department of Indetstriai�9(ccic�etats M 1 Congress Street, Suite 100 - Easton, MA 02x14-2 0x7 ~� wrvw.mass.gov/dia Workers' Compensation TOBBMBD'i3')r:THTHEP RMl[TrTINGAUTHORIT'S'.tkicians/Plumbexs. Applicant information Please Print Legibly_ S LL,C, Name (Business/Organization/individual): !� ex �Jls :K��� oC�' S Address• 10MV 'h 1rJ U 0- one #: $ % 6 O 203 d City/Slate/Zip: 0� Cn O198 . Are you an employer? Check the appioprlate box: Type of project (fegmred): 1.[]I am a employer with employees (full and/or pari time).` 7. Q New contraction ,21:11 am a sole proprietor or partnership and have no employees working forme in 8. [1 Remodelirig any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10 0 Buil(�ing addition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions 5. [WI am a general contractor and I have hired the sub -contractors listed on the attached she 13, 0 Roof * airs These sub -contractors have employees and have workers' comp. insurance., OA � `� 14. ❑ Other 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and v+e have no' employees. [No workers' comp. insurance required.] ny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information - kA* Homeowners who submit this afTidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors fiave employees, �liey must provide their workeis' comp. policy number. X am an erriployer that is pi ovidir�g workers' compensation insurance for my employees.' Below is the policy andyob site information. Insurance Company Policy # or Self -ins, Lic. Expiration.Date: rob Site Address: City/State/Zip: Attach a copy of the workeis' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance verification. X do hereby Phone #• 1 . of perjury that the information provided i love `is true and correct: official use only. Do not write in this area, to be completed by city or' town officiax _ City or Town: Permit/License # V1 Issuing Authority (circle one): i 1. Board of Realth 2. Building Department 3. City/Town Clerk. 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone ACORLO0 AC� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1/14/2016 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), AUTH?PZED 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 CONTACT Lauren Goldman NAME: Cross Insurance -Peabody 139 Lynnfield Street PHo N (978) 532-5445 ac No: (97a)s32-2217 AIL ADDRESS: lgoldman@crossagency. com INSURERS AFFORDING COVERAGE NAIC # NPP8290737 INSURER A :Western World Ins. Co. Peabody MA 01960 INSURED INSURER B:Safety Indemnity 33618 INSURERC: Nexus II Services LLC INSURER 0: P.O. BOX 2823 INSURER E: PERSONAL &ADV INJURY $ 1,000,000 INSURER F Woburn MA 01888 COVERAGES CERTIFICATE NUMBERCL15102253381 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MM/DDIYYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR NPP8290737 8/12/2015 8/12/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ JE a LOC OTHER: GENERAL AGGREGATE $ 2 , 000 , 000 PRODUCTS - COMP/OP AGG $ 1,000,000 Damage to Rented $ 50,000 B AUTOMOBILE LIABILITY ANY AUTO ALLOWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS X AUTOS 3116632 11/10/2015 11/10/2016 COMBINED SINGLE LIMIT $ Ea accident X BODILY INJURY (Per person) $ 500,000 BODILY INJURY (Per accident) $ 500,000 PROPERTY DAMAGE Per accident $ 100,000 Medical payments $ 5,000 UMBRELLA LIAB EXCESS LIAB d OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFIC ER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE ER _ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Elizabeth and Neil Thurber 210 Farnum Street North Andover, MA 01845 ACORD 25 (2014/01) INS025 r9nf4nii SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lauren Goldman/MDl ,p C� . I'd0fe ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts - Depar"ent of public Safety -_� Burd of Building Regulations and Standards Pndar Camtruction ,qulser iwr g' P License- CS -073991 �i4S I� GIgRALDWHi'I'E,-. .. � rr. 23 GLVNDALE DliP iDA�Rs Zt A 619217,',�� Expiration o--,�.•M '�'- 000712016 Comm-issioner 1 a r/Ir.{'rNlrrr;rru�ril/r 1�jrS�ar/ri�rl%~ t3iiicc otConsnmer �ilfiirs & Business anon License or registration valid for indwidul use only i before the expiration date. If found return to: 7ME IMPROVEMENT CONTRACTOR pe' Oflce of Consumer Affairs and Business Regulation eglstratlon: 129177 10 Park Plaza - Suite 5194 Expiration: 7119/2015 1 ideal Bo MA 02116 is Gerald White f Gerald White 23 Glendale Dr'..,-- ~ Danvers, AAA 23 Undersecretary Not valid without signature s R Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contra, ctor Registration Registration: 129177 Type: Individual Expiration: 711912017 TO 259000 Gerald White Gerald White 23 Glendale Dr Danvers, Ma 01923 =A 1 4 df "l r ��' �',r. Yr+/.*r NI7k'+95!!N �g � !//rii(1f�ti.:!'✓✓r" * .Ottke of Coosteaaer Aflsits dY #rosiness liegulslaan i 3NOME IMPROVEILIW Cf}f�ITRACTOR . u "1.14f,.'q R°M 12$177 Type, L k ` Exptratlort: 771912017 Individual Gerald Whhe Gerald White 23 Glorrdase lar Danvem MA 01923 11>rderac etr�r 'Update Address and retnra card. tilaile.reason for change. 0 Address 0 Renmal 0 Employment 0 Lost Card Urense or registration -.-slid for individal use only before the expiration date: If round return to: office ofC,onsumcr Affairs and Rusiocss Rtgulation 10 Park i laza • Suite 5170 Boston, MA 02116 Not valid without sipature y s 4. 'Update Address and retnra card. tilaile.reason for change. 0 Address 0 Renmal 0 Employment 0 Lost Card Urense or registration -.-slid for individal use only before the expiration date: If round return to: office ofC,onsumcr Affairs and Rusiocss Rtgulation 10 Park i laza • Suite 5170 Boston, MA 02116 Not valid without sipature