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HomeMy WebLinkAboutBuilding Permit # 6/30/2015 01 %AORTIJ BUILDING PERMIT TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION Permit No#: A % Date Received A T 6 D C U5 Date Issued: IMPORTANT: Applicant must complete all items on this page j /- �— LOCATION 3 El T L( �r064— 3 Print PROPERTY OWNER L I'c ci VIJ 611 Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building El One family 0 Addition �4w�o or more family [I Industrial El Alteration No. of units: [I Commercial El Repair, replacement [I Assessory Bldg [I Others: 0 Demolition El Other 8W�M All ,5 Wetlan' q gp Floodplain Qistnct 2AK v WOF. I p DE �CR17PION OF WORK TO BE PERFORMED: A Identification-,Plea e pe or Print Clearly OWNER: Name: 110M Lk��()r Phone: 9-+&-S� Z Address: - ddress: 4 Contractor Name: o , � Phone: '-SDS® Email: 1"a rncn=rU�tIr Address: -c " r 19 35 IS- Supervisor's Construction LicenseT T C) Exp. Date: 0 of Home Improvement License: —Exp. Date: ARCHITECT/ENGINEER AcGIV Phone: 6-V Addressis' . 2 Reg. No. 4-ci M I i rol V FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. 0 Total Project Cost: $ V�0 -C9C FEE: $- , �`6 Check No.: a I )<-T) Receipt No.: � L/ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund hf'G ttORTH Town of z E . I, Andover C, LAKA h ver, Mass, COC ICHEW/CK 01' If 1-i ORATED Okf' S s � BOARD OF HEALTH PERMIT T Food/Kitchen LD Septic System THIS CERTIFIES THAT ............./.����.........<Z! .G.1.: ,;; r��d........................................................... BUILDING INSPECTOR has permission to erect .......................... buildings on ..�.7�../l!��;,�.,5' ...................................... Foundation Rough tobe occupied as .........:�¢ `.� ..... C. ....................................................................... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR LESS C TRCTIO TARTS Rough Service ........... .... . ..�..,.................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Islay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. DIAMOND CONSTRUCTION, INC. 1 Worcester St., Suite 10 Grafton, NIA 01519 , ch ailiondeonstl"U ctionlii a(�l),gmai i.coni MIC License# 176910 CS Lie. 080830—Hanna CONSTRUCTION AGREE1 ENT 'I HIS AGREEMENT is made at On this day___ of--,-- of 2015, by and between DIAMOND CONSTRUCTION, INC. (hereinafter the "Contractor") and_/,'`r,�� the <— "Owner") located at DESCRIPTION OF SERVICES Diamond Construction, Inc. agrees to provide labor, materials, equipment and other facilities required to complete the following work: Scope of work at the property Located at _ which Owner warrants that it is the owner with full authority to enter into this agreement. , jJ Diamond Construction Inc. agrees to start this project ons and shall complete the work on -41 ��, �( If the project passes [incl uispection and Owner refuses to sign Notice of Completion, then Contractor may sign this Notice of Completion on behalf of Owner as it will be assumed that lie is satisfied with the work. PAYMENT I 012015- This document is binding and has serious legal consequences_ feel free to consult with a qualified attorney prior to signing. Full insured SCOOP OF WORT{ 1) Project NlaIIagel'inspc:cling thf;project all the icne 2) Install Safety equhment before suirtingworl mg 1000% 3) Cowx hoi,.sc G stn'lttQ,wic'n Earpaulias for the pcot-cdon 1001r'o 4) 100% 6) Re-nail all loose roof boards 1000/0 8) Install 1) reel:i( ;tn(!water strield at ill gutLer edges es ind � alleys 6 acct and 3 treet can r alces,'l_="om h.irig to ills fascia Am 9) `filer Paw V 1t❑ os Deck arn7er❑ 10Ja9fa Dia-nond Deck CeriainTee i!If 10) Iusulll 0"to the roof deck In i"over hang to the fascia �l F.11il) Y s - l .ninI2 dl'I 7 edges LQ.'01 eClgE'S. bSWte �T] i[[z.rr-''t' _- t—f - 12) ��� 13) Apply stakcr strip at eaves 14) Califorr0a cio or Iv ave v lilcy (If`anv} T- 15) Install Ilevv room ilrmg- s on ve of pipes -- -------- 16) --16) Install new Midge vent c bis snow coitn03, I 17) Timhe `I eY P i;l�c ca?3 ❑ j to(,% 191 � I DIAMOND CONSTRUCTION, INC. 1 WORCESTER ST.,Suite 10,GRAFTON, MA 01519 Ph: 508-508-365-7300 * E-MAIL: diamondconstructioniria@ginail.cotn 20) hist ala nev✓,oof s4 im.-A<, Ufc'F;ttte. j -- - 21) all nit*ac -(i low rcot 22) (J.;e 3 elel nmi net to rernovc all malls ,roam arom,c� 01c 110L15L 2-3) G ilcuiicai�a nasli?�g f✓1t'� ���its L��1�ttr;�psle l �, 2 y 1 26) - -- 27) — I 2 S) -- � 29 i'vTatc,,il sisplal tic+"oy she ccasloan�r R I ; 30) bdilte Ial supplied bl lbe contracror31) I ( 32) ; s ' i I I - ---- i i i � ( I I , t � I r -i IvT OTAL -. — ------ - - --- -- — - - — -— s C t DIAMOND CONSTRUCTION, INC. 1 WORCESTER ST., Suite 10, GRAFTON, MA 01519 Ph: 508-508-365-'7300 ¢2� E-MAIL: diamondconstructionma@gmail.com DIAMOND CONSTRUCTION, 1W. Owner agrees to pay Contractor the amount of ni .tr (subject to adjustments such as additions and deductions pursuant to authorized change orders). Owner shall pay for all permits, licenses and easements for permanent structures or permanent changes in existing facilities. In the event Owner obtains their own permits, Owners shall be excluded From Residential Contractor's Guaranty Fund pursuant to Mass. General Laws Chapter 142A. City permits and licenses to complete the work shall be paid by Diamond Construction. All payments are due and payable upon receipt. Payments will be made according to the following schedule: d7,7, .00 Upon the execution of this agreement. Includes material costs, permit costs, and. dU mpster fee; .00 (whichever is greater) of the contract sum upon commencement of the work, $ j .00 (whichever is greater) of the contract sum upon completion of the work. If material/equipment required were special ordered there will be no exchanges, refunds, credits, or returns. Payments shall be made in available U.S. funds and payable to "Diamond Construction, Inc." Payments made will be non-refundable once Contractor starts to perform, starts to demobilize in any way, engaged subcontractors, or has ordered materials. All payments will also be subject to deduction for administrative expenses. Owner agrees to pay $50.00 for each and any non-sufficient fund checks. If an invoice is not paid when due, interest will be added to and payable on all overdue amounts at 6% per year. Owner shall pay all costs of collection, including without limitation, court costs and easonable attorney fees. r PLAN S/S P FC I F ICATION S Prior to the start of the work, Owner shall provide to the Contractor all plans, surveys, specifications, drawings, blueprints, and reports describing the physical characteri sties, soil, geological and subsurface conditions, utility locations, and similar documents that may assist Diamond Construction, Inc. in properly evaluating the extent and character of the work at the estimate stage. If any drawing, blueprint, floor plan, or specification violates or is in conflict with local law or/and ordinance, and where any such situation results in any necessary changes in the work, then Diamond Construction, Inc. shall be entitled to a reasonable adjustment to the Contract I:-)rice and time to correct it. 7 C/2015- This document is binding and has serious legal consequences. Tett free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. (IJANGE ORDERS All change orders shall become part of this contract and incorporated by reference. The Owner shall notify Contractor of any changes in construction or plan and shall provide revised drawings, plans, or specifications followed by a change order. If the changes in the change order pertain to differing site conditions, errors in the plans and specifications, or other circumstances beyond the control of the Contractor (including acts by the government, tire, flood, unusual delay in transportation, abnormal weather conditions, labor disputes, strikes, war, lack of worksite access, acts of God, natural disasters, or acts of third parties), then Contractor shall submit to the Owner an estimate and proper adjustments to the contract price and time. If pricing is inapplicable, cost of the change or the amount of the adjustment shall be determined based on the cost to Diamond Construction plus reasonable amounts for overhead and profit. Contractor shall not be obligated to perform changes in the work or additional wort: until the Owner has approved, in writing, the changes to the contract price and time. SITE CONDITIONS Owner acknowledges the duty to disclose any and all pertinent and known hazardous condition information to Contractor and subcontractors and may not mislead or conceal any material or property facts such as how many layers of roof or type of roof was originally installed. Where a site owner does not disclose facts that subsequently cause delay or need further cost, then the Contractor will. then be entitled to recover damages and a change order shall be allowed for additional costs. After consultation and agreement with the Contractor, Owner must immediately make an adjustment in the contract time and payment by issuing a change order if Contractor discovers and notifies owner of any of the following: (I)Ilazardous Materials deemed by any federal, state or local governmental authority to pose a present or potential hazard to health, safety, or the environment; (?)Any Subsurface, visible, nonvisible, or latent physical conditions that are found unexpected or that seem different from the work agreed upon; (3) Unknown physical or other conditions that seem strange or materially different from those encountered by Contractor's during and based on his construction experience. 3 C/2015- This document is binding and has serious legal coasegttences, feel gree to consult with a qualified attorney prior to signing. DIAMOND CONSri T "ION, INC. Upon discovery of any of the above, Contractor shall immediately stop work at that particular site. Contractor shall have no obligation to perform any corrective or remedial work. TERMINATION Owner is required to first provide a 5 day advance notification of any alleged breach and allow Contractor 10 days to cure such alleged breach. Owner may terminate the Contract if the Contractor lulowingly disregards applicable laws, statutes, ordinances, or local codes, has committed a material breach, if contractor made an assignment for a creditor, or becon.les insolvent. Diamond Construction, Inc. may terminate this Contract if: Owner becomes insolvent, will not allow access to the site, Owner commits a material breach or fails to pay an invoice on time; work is suspended for 10 consecutive days through no act or fault of the Contractor or a Subcontractor, Sub-subcontractor or their agents or employees; or there is a stop work order by any court , or any stop wort: order issued by any town or authority. If any of the above occurs. then Diamond Construction shall send a written termination notice to the Owner and recover from the Owner payment for work performed, including reasonable overhead and profit, costs incurred by reason of such termination, and damages. If the Owner terminates the contract on convenience, he shall communicate of this intention writing to Contractor as soon as possible. Then, on or before the termination date, Contractor shall be paid its actual costs for that portion of the work performed to the date of termination and for all costs of termination, including demobilization and any termination payments already made to vendors and subcontractors, plus 20 percent of all such costs for overhead and lost profit. INSURANCE The Diamond Construction, Inc. shall carry and maintain throughout the project period valid Workers' Compensation and General Liability insurance. Certificates of insurance can be provided.to Owner upon request prior to commencement of'tile work. Contractor ensure that the general liability coverage to includes the Owner as additional insureds for claims caused in whole or in part by the Contractor's negligent acts or omissions during the Contractor's work. 4 C/2015- This document is binding and has serious Icgal consequences. Peel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. The Owner must have and maintain throughout the project and until completion Property insurance coverage (Builders Risk Insurance or other suitable cover ) at minimum the amount of the contract price. Property insurance including loss or damage shall cover file Owner, Diarn_ond Construction, Inc., Subcontractors and Sub-subcontractors for their interest in the Work and shall insure against the perils of lire with extended coverage and physical loss or damage including coverage for theft, vandalism, malicious mischief, collapse, debris removal. Owner waives all rights of recovery against the Diamond Construction, Inc. for loss of use of the Owner's property, including consequential losses Clue to fire or other hazards, however caused If the Owner does not have and will not obtain property insurance, the Owner shall inform Contractor in writing prior to start of the work. If the Diamond Constrt.iction, Inc. is darnaged by OwncCs failure to have or maintain insurance as described above, without notifying the Contractor, then Owner will be responsible for all costs associated to such damage. Owner and Diamond Construction, Inc. waive all rights against each other and against all other Subcontractors and Owner for loss or damage to the extent reimbursed by any property or equipment insurance applicable to the work, except such rights as they may have to the proceeds of such insurance. If any applicable policies of insurance require an endorsement or consent of the insurance company to provide for continued coverage where there i.s a waiver of subrogation, the owners of such policies will cause them to be so endorsed or obtain such consent. Owner must not use or borrow any tools or ladders owned by Contractor. If Owner, without consent, uses Contractor's tools or Ladder, then he shall hold Contractor harmless of any liability whatsoever and will not place any claim on Contractor's insurance. DELAY Diamond COnstrUction, Inc. shall provide to the Owner notice of any delay in work. for changes necessary due to work schedule, suspension of work or any other unforeseen cause beyond Diamond Construction's control and/or where there is no fault by the Contractor, its Subcontractors or suppliers. The contract time shall then be extended as necessary to accommodate delays via change order. SUSPENSION OF WORD 5 02015- This document is binding and has serious legal consequences. Feel free to consult with a qualified attorney prior to signing. DIAMOND CONSTRUCTION, INC. Diamond Construction, Inc., May suspend work Ior Owner's failure to pay invoice on time, due to differing site conditions, or for changes requested by Owner where Contractor deems it may suffer financial hardship. if work is stopped for a period of 10 consecutive days due to no act or fault of the Contractor or a Subcontractor or their agents or employees: or if because the Owner has repeatedly failed to fulfill the Owner's obligations under the contract then Contractor, at his discretion, may immediately suspend work, terminate the Contract, and recover from the Owner. The Owner may suspend work with advance notice to the Contractor. The written notice shall specie the date and the estimated duration of the suspension. Any Owner suspension shall not exceed 24 hours. Once the suspension is removed, the Contractor shall resume performance of the Wort: as soon as it is possible. Owner will be liable then for all and any damages for suspension of work which may include costs of demobilization_ extended overhead costs,jobsite costs, etc. Any suspension of work under this Contract will also suspend the progress and completion dates. FORCE NIAJEURE If performance of this agreement or any obligation herein is prevented, restricted, interfered by reason of act. of God, fire, flood, or other natural disaster, malicious injury, strikes, lock-outs, or other labor troubles, riots, insurrection, war or other reason of like nature beyond either party's reasonable control then performance of such act or obligation shall be excused for the period of the delay. If any delay under these circumstances exceeds days, then either party shall have the option to terminate this Agreement. INDEMNIFICATION Diamond Construction, Inc. shall indemnify and hold Owner, its employees, officers, directors, and affiliates harmless from any loss, cost, expense, or damage claimed by third parties for property damage and/or bodily injury, including death, to the proportionate extent such loss, cost, expense, or damage arises from the negligence or willf it misconduct of Diamond Construction, Inc., its employees, officers, or directors in connection with the Contract or project. Owner shall indemnify, defend, and hold Diamond Construction, Inc.. its SUbcontractors, employees, officers, directors, and affiliates harmless fronh and against any and all claims, demands, causes of action, liabilities, loss, cost, expense, or damage claimed by third parties Por property damage and/or bodily inju>y, including death, to the proportior)cite extent such loss, cost, expense, or damage arises from the negligence, fault, or 6 C/2015- This document is binding and has sanious legal consequences. Feel free to consult with a qualified attorney prior to signing. DIAMOND 1 J 'A`I , INC. willful misconduct of Owner, architects, designers, its employees, officers, or directors iu connection with the Contract or project. WARRANT' Diamond Construction, Inc. warrants that the work will be conducted in good professional workmanlike planner, and warrants that materials furnished will be of good quality and new. If within two years after the date of completion any of the work, it is found not to be in accordance with good craftsmanship, the Contractor shall correct it promptly after receipt of written notice from the Owner. The Owner shall give such notice promptly after discovery of the condition. During the two-year period for correction of Work, if the Owner fails to notify the Contractor then Owner waives the rights to require correction by the Contractor and to make a claim for breach of warranty. In the event that any of the provisions of the warranty shall be held invalid, the remainder of the provisions of the warranty shall remain in full force and effect. Where Contractor's repair warranty work involves the snatching of existing finishes or materials, he will use his best efforts to match existing finishes and materials. However, Contractor docs not guarantee an exact match due to such factors as discoloration due to the aging process, difference in dye lots, and difficulty of exactly matching certain finishes, colors, and planes. This warranty specifically excludes consequential damages and the following: 1. Damage on shingles due to ordinary wear and tear, abusive use, normal wear and tear, improper use, misuse, or lack of proper maintenance o1 the home or its component parts or systems. ?. Defects, or loss or injury not caused by the negligence of Diamond Construction, Inc. or its subcontractors. 3. Defects in items installed by the Owner or anyone other than Diamond Construction, Inc. or its Subcontractors or defects in items supplied by the Owner. 4. Conditions not caused by Diamond Construction, Inc. and or it's Subcontractors resulting from condensation, or contraction of materials. ACCESS 7 0.'/2015•- This document is hinding and has serious legal consequences. Feel free to consult with a (1twlified attorney prier to signing. DIAMOND NS`s 1 , INC. The Owner shall provide ample access to the site to Diamond Construction, Inc. throughout the project. Any delay or blocking of access by Owner will entitle Diamond Construction, Inc. to a reasonable adjustment in the contract price and time, INDEPENDENTCONTRACTOR STATUS The parties agree that the contractual relationship between Contractor and Owner is of an independent contractor. No documents signed create a partnership,join venture or any other relationship between the parties. ADDITIONAL CLAUSES. * Diamond Construction, Inc.'s suggestions are not a substitute for professional engineering, architectural, or design services, and are not to be relied on as such by Owner. This agreement represents the entire agreement between the parties regarding the work described above and supersedes any prior written or any oral agreements or conlnl.unications. This agreement may only be modified or terminated in writing. No breach of any agreement, warranty or representation shall be deemed waived unless expressly waived in writing by the party who might assert such breach. * If any clause of this Contract is determined to be illegal or unenforceable for any reason, it shall be severed from the Contract and the rest of the Contract shall be given full force and effect. The terms. covenants and conditions of this Contract shall be binding upon and shall inure to the benefit of the successors and permitted assigns of the respective parties to this Contract. * The agreement shall be governed by the laws of the Commonwealth of Massachusetts. The parties hereby agree to submit to the jurisdiction of the courts located within this Commonwealth for any controversies arising out of this agreement. ® Owner hereby acknowledges he/she has had ample opportunity to consult with independent Legal counsel, has read it, understands it, and is signing it freely and voluntarily. If Owner is signing this azn greement at his home, or at a place other than at the contractor's office or business, then there is a 3-day cancellation right. (Sec Cancellation Notice) d Owner Name: t l Mr re's! " E Diamond Construction, Inc. Owner Signatfa John Malo President Cell Phone: ' (508)365-'7300 E-Mail: ­ t C t `� dei r �.0 i diamondconstructiomna(�gmail.com 8 C'/2015- 'Phis document is binding and has serious legal consequences. Fcel free to consult with a qualified attornev Prior to signing. __. ., . ..._.. __ _... __ --... SECTIONS: : C", ...............------ kh tt1�IFs�'f t1C 'V"f(�1�S�FFYIt.f',S 5.1 Licensed(ora tn,let iraattiarpaa rvisoa (C81,) - _... _._. ... Nana ok fr License Numher F;xprrratmn Date Jar Idr r / Add] (1 ��!� .." �" S _Fl__... Unrestricted CrLfo 35(rU0 Gu 1 t,_)_..__. _ ..___ Srp;naat / fi ltr�lrrcted 121"arrarly Iawrllrup, - ... / Ah Ni i rrrzry 6)rrly R( lac rduntr<aI Fdooiropy ova�ruaf lelep7h.ne --.. - - ® � WS Rcsid<ntr,al Windowacrd Siding SI ttr>idcnti al Solid Fuel I li3rarrana} e1f>prh arauc In,tallsation 1 mail Address _ .- _._ _ 17 Residential Dc,raaolituan 5.2 Register°ad Home Imprrc Vement Contractor(11'1C,) I11C Conrpany Name or FItC, it p iytrarat Narroe; IZc, isuatron Number ....-. - _.. Address f xprr,ation Date, Signature 1 rlephone. ......... _-... ........ E-mail Address - --- -- -- - ...... SECHON 6. QAI(1ll(�t+,RS' COMPENSATION t1�SURAN(E AFFIDAVIT (M.(�,t,. c. 152, ZSC(6)) _._.. - _ .. ---. _. Workers ConapensatiOil must,be completed and wsubrrarttcad with this application. Failure to provide this affidavit will result in the,denial of the, issuance of the building p:rerrrait. _.._.. _. ._ _._.._-... ._ Signed Affidavit Attached? Yes ...... .... l I ritu .. .. .. i_:I _§E_C_1 -— -- - ------- ._- - -- _ ��;(;'�F4D1'�"7a: d�llrl �,��.A�J'll't fl(�t�.���A�'FC�i 'F C��Ff.Fi t"fDIl���1.Ri��;��`PVA t t��,N OWNER'S AG Nf.'CI'R(,OWAt._'"t OR APPLIES FOR BUIILDINCI fFF"RMIT its Ownc,r of the subi ect property hcare,by authorize w �����e crw w,�%� _ ��ts��r 12 I Ll C i_7 0 - _-_....__. to act on my bel-rtalf, in tall matters relativ work authorized by this building prernait application. SI Haat, of Ciwc � C7 Thy A tact Dat(, SECTION 71a: CA T"rl➢I'W d:>R AU'➢"Fff:.9RfZED AGEN t)ECLAffAa't ION Owner or Authorized Agent hereby declare than the statements and in iarmation on the foregoing application are tra.ae hand accurate,to the best of any knowledge and behalf ............_..........._.-__.....__ _._ .__....._ _ ---- ---- ---__---- Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 1. Ar-r 6wne,r who obt<am,a burlclirrg lac unit to do lits/lar,r owra w<>r(<,or aaa c>wracr who Ian c°'s an tanreg,rv,ta rc:d ooratractcar. (not registered in the Home Improvement Contractor(I-IIC)Program),will not have access to the arbitration program or guaranty Fund tinder M,G.L c. 142A. Cypher important irtlorm atiora ora the HJC"Program hand Construction Supervisor Licensing;(CSL)can be F«tard in'780 CMR Regulations I l O.R6;and 110.1 5,respacctively. 7. Whcra substar�tiaal work is planned,provide the, information below: Total floors area Sc. Ft (ii°rcludmgr gOriage_finished harscment/attics,,decks or porch) f �' l ) _ Gross livrn�p area Sep. F t)_._._.... Habitable roorn count lslumber off rep paces _ Number of bcchooms Ntrrrrber of'bat,laraom4r NUMI cr ofh;a117hathS `hype of heating Sys lei dumber of decks/paorehes Type ofcooling,systeirt_ _-- ___...- _.._.__..._ Enclosed Oprep _..... �- The Coli ri.awealth ofKI tdgss v��°h s 6 fAce- nes Office ®f Iffives g aiiolig 600 Yr aghiggtoia S eet Boston, MA 07111 Workers' Collanpefo.s afion A>j surance Affidavit: �anil�lterr�/��>Ia�Ir��fr®>r�/►El��trrru�i���/�"ll�n�ll�e>i� Malmo (Business/Organization/hidividual): � M/0- " AC]CjYeSS: =-t.sem 4 city/state/Zip: Phone #:_6Vf ;,s^ C� Are you an employer? Check the appropriate boy.— Type of project(required): 1-El I am a employer with T 4. �, I am a general contractor and I have hired the sub-contractors 6. New construction employees(full and/or part-time).' _ 2_❑ 1 am a sole proprietor or partner_ listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Buil fiiig addition [No workers' comp. insurance comp. insurance. I required.] 5. �] We are a corporation and its IO.j� Electrical repairs or additions 3.[} I am a homeowner doing all work officers have exercised their I LEE Plumbing repairs or additions myself [.No workers' comp. right of exemption per MGL 12.F1 Roof repair's insurance required.]; c_ 152, §1(4),and we have no employees. [No workers' 13.j Other comp. insurance reQUIrec€.] ''Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit uidicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. AContractors that check this box must attached an additional sheet showing the mune of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers comp.policy number. I rirrri art errrployer tittif is provitlirrg ivorkers'coiiiperrsadoii iiistir it,rice,for fray eniployeeS Below is the policy andjob site irtformadon. i Insurance Company Name:1 U t,��p t2i�©clv3 j- 6 6 y K c Policy#or Self-urs.Lic.#: \/W C- l©D- 6l 77 [q` ,2015-A Expiration Date: /av Job Site Address] �}-� 9ai a 5 7` City/State/Zip:Ave Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the Imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement tna y be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci,fy under the pahis and penalfies®f'peryirry that the tri,formirtron provided above its.t-riae and correct -- Signature: Date: Dso I?hant V. �S��f S` 3 OD Official use only. talo not write in this area, to be completed by city or'town official f� City or Town: Permit/License# �! Issuing Authority(circle one): 1.Board of health 2. Building Department 3. Cityflbwn Clerk 4. )Elects ical Inspector 5.Plumbing Inspector 6. Other Contact Persona Phone#: 0 DATE(MMIDDNM) A�Ro CERTIFICATE OF LIABILITY INSURANCE 06123/2015 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 CONTACT ART CALVILLO NAME: _. NEIGHBORHOOD INSURANCE LLC. PH Na.Exq 978-582-1178 FAX Ne); 978-582-1182 —— -- 9 MAIN ST ADD-REACALVILL0128@YAHOO,COM SUITE 3A1 INSURERS)AFFORDING COVERAGE j NAIC p SUTTON,MA.01590 INSURER A: CATLIN SPECILATY INSURANCE INSURED INSURER B: COMMERCE INSURANCE DIAMOND CONSTRUCTION INC. INSURER C: A.I.M.MUTUAL 1 WORCESTER ST INSURER D: INSURER E; GRFTON MA 01519 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - - ADOL SUER - -! POLICY EFF i POLICY EXP - LTR TYPE OF INSURANCE POLICY NUMBER M DDtYYYYI;IMM1DDNYYYl LIMITS �COMMERCIAL CLAIMS-MADFGENERAL X LIABILITY OCCUR ' EAMAGECH 0R_RENCE $ 1+000+000 }� — A !2000200208 041061201504/0612016 DAMAGE 5 00 i I PREMISES Eaoccurrenco- f[GIN'L i MCD EXP(Any ono person) '.5 5,000 , 00 I PERSONAL&ADV INJURY (5 1 000 000 ,AGGREGATE LIMIT APPLIES PER' 'i j GENERAL AGGREGATE S 2,000,000 { PRODUCTSC_O_MP/OP AGG $ 2+000,000 POLICY JECT LOC -_ -- �tF--iii OTHER $ B I AUTOMOBILE LIABILITY ( COMBINED SINGLE LIMIT $ 1,000,000 l- Ea accident_ + AUTOS X Auros 032577 0310112015 BODILY INJURY(Per person) $ I-- --, yy --- -- -- --_ �X ANLOWNED SCHEDULED 31011/2016 DI Y AUTO $ —1 I, PROPERTY DAMAGE - Per aeddent _I S HIRED AUTOS AUTOS I -C--- 1-.------ .- t --- ----- �$ EACH OCCURRENCE 5 OCCUR _ --- _— EXCESSLAB LIAB ;CLAIMS-MADE( AGGREGATE DED RETENTION$ ( $ LL C WORKERS COMPENSATION j PER OTH- ' AND EMPLOYERS'LIABILITY YIN I-__:STT3T. ..�_ ER ANY PROPRIETORIPARTNER/EXEGUTIVE VWC-100-617419-2O15A 04106(2016 E.L.EACH ACCIDENT 1$ 1+000+000 OFFICER/MEMBER EXCLUDED? N I N 1 A -_._-_______-_--_._— ---__. 04108 2 5, (Mandatory In NH) I E.L.DISEASE-EA EMPLOYE $ 1,000,000 It yes,describe under DESCRIPTION OF OPERATIONS beau 3 EL DISEASE-POLICY LIMIT S 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR ISIONS. 1600 OSGOOD ST BUILDING 20 AUTHO DFI EP E NJA SUITE 2035 r NORTH ANDOVER MA,01845 ,f!. ©1 8-2014 AtORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD -w_ - = _ Ofl�e of,o�sz.�.r.-,saa rs B,siness R�SaSs#lo- License or registration,- l;d or tnd=ridnl use only II��iE II�IPRC3�fE11lEttT CONTRACTOR before the exp ration date. 11,found return,r.zo: E�SisY;�itOn_ 176910 Type: Office of Consumer affairs aaac9 Business Regulation ".Enpiratton: 10/1012015 Corporation 9 Park laza-5€ite 5170 Boston.NIA 62116 ; 7iAMICND CCNSTRJCTiON INC. � JOHN MALL 637 GRAFTON ST APT 3 � VJORCESTER, MA 01604 lzclerse�ro �� r Notvalid withouts€-nature --- I i RYAN K HANNA. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section l OA. The debris will be disposed of in: (Location of Facility) re of Permit Applicant Date hyS lv 15Stfe- -74jz- s �6em 4 nee-