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Home My WebLink AboutBuilding Permit # 10/6/2015 IJIL IN PERMIT o�Na DT TOWN OF NORTH A o APPLICATION FOR PLAN EXAMINATION „u Permit No#: Date Receivedq,ED " �y Date Issued: SSgcHus�� pp must complete all items on this page IMPORTANT:Applicant rl r ,J l 11 N' f".J at9`llVrp,>,u I N I : � ;i'ePmib,w TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial N/Repair, replacement ❑Assessory Bldg Others: ❑ Demolition ❑ Other I ..l ..,. � ,., / I ,r / c/ � �1 rJ o ilii i,�� , // / f/ f J J�/ ( ❑ Jr I �, , , �r/r 1 DESCRIPTION OF WORK TO BE PERFORMED: J_J b,r e Identification- lease T pe or Print Clearly OWNER: Name: Phone:s 1 Address: / �1�1 �/, f ,,�f f „/ ;r, 11 I f r/((!//1 i/ /i 1,l e// 1111 l / i rlr /l / I i , ,Y`, � r ' rrJ„r r,/ •%„i r „rrr I I , er , u i , Jrf / C I I 1 I , r r r an u ➢ p.�u; G Y I'�YIIIc +' 7?/'. l ��1//��l�� r I I I , o.:�,��, I I,, ! ��.. ARCHITECT/ENGINEER .L �w�t�, /hc4 Phone: 1,� Address: Weg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ /0- r - OO_ 60 FEE: $ �2 L:.! Check No.: ��.,��,�� Receipt No.: NOT + Perso,s contractln with unregcsred contractors do not have acces to the g ty unci signature of Age t/ vvner ;Signature of contractor f tk®RT H - . A town ofE 1�' ® ^�'• w ndover0 r Zd L 5 ® . • h ver, Mass, L) � o COCMIC.'WIC. y1. �®ADRgTED ,S V BOARD OF HEALTH Food/Kitchen PERMIT T LU Septic System THIS CERTIFIES THAT BUILDING INSPECTOR `` .. Foundation has permission to erect .. ... buildings on ......L 3 e`^" 1 Rough to be occupied as .......... .... ..... ...... .. .................. .. ......e.ze....... .......................... 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 PERMITI 6 MONTHS ELECTRICAL INSPECTOR LES IO TARTS Rough ... ............................ Service ..............X............. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedy the Building Inspector. Burner Street No. Smoke Det. NCS , Inc. 314 Clark Street North Andover MA 01845 978-685-0568/fax 794-3780 Construction Work VERS 3.0 August 28, 2015 Proposal submitted to: NA Historical Society Address: 153 Academy Lane North Andover MA Service Address: same Phone, Email: jdlai@aol.com Salesman: Norman V. Lee Contact: Joe Lagrasse and Mark Yanowitz We hereby submit specifications and estimates,subject to all terms and conditions as follows: SUBJECT TO CHANGE, BASED ON ANY NEW DRAWINGS AND CHANGES IN SCOPE Dig along foundation and expose along entire rear of building, as determined by plan date 7-2-15 Remove slab concrete on rear doors and replace in similar size in granite Remove wall along Academy Road to create and facilitate work area and reinstall with additional 10' 45 degree angled wall,then graded to support soil again Power wash and prep exterior of basement to allow waterproofing to reduce water infiltration Install drainage pipe per plan and tie in downspouts as indicated Back fill and compact as per plan Clear, cut and grade rear of building in preparation for new New England field stone wall Install new slab for new wall,install wall and install drainage behind per drawing Install friable loam in damaged areas,grade, roll and seed all disturbed areas $77,120 Install new gutters, down spouts and leaf guards to replace existing, Drip extensions,wedges, roof hangers, with 3 valley guards And 9 drain caps,fascia(18') removal of old gutters (will need further discussion and review) Budget $4250 Remove and install 510 bit Conc.Walk Budget $8500 Spray foam and Waterproofing Actual $4900 Atrium Domes for four windows Actual $4760 Subtotal$22,410 Total Budget $99,530 Alt pricing Repair sump pipe and replace catch basin w/assoc patchwork* Budget $7500 *need plan/design to quote real number Notes: Permitting by others,at client's expense Does not include any steps or railings or fencing Does not Perennials,Shrubs or Woody Ornamentals Conservation Bond to be paid by client Any changes to scope of work will need a change order with change to pricing. Done during normal business hours of 7am-4pm Price good for 15 days Proper watering is critical for the health of the lawn-please review watering instructions contained in this contract.Ledge or other issues encountered that will affect pricing,job duration,or other unforeseen issues as the project is ongoing will be discussed with the client,and change order submitted and signed off on to continue work. Client Initials `�; �.�- - 1 - Questions?Call us,write us and check out our website @ www.ncsne.com for more information onour other services. TERMS & CONDITIONS PAYMENTS AND DISBURSEMENTS: Customer is responsible for obtaining any financing he deems necessary to comply with this Agreement. If Customer is obtaining financing form a third party, Customer agrees to apply for such financing without delay and this Agreement is subject to Customer being approved for such financing. All payments are due and payable as specified in the Proposal/Contract. Northeast Contracting Solutions reserves the right to assess a$25.00 fee if Customer requests us to re-invoice them for any reason. Overdue payments will bear a 1.5%service charge. Failure by Customer to pay any invoice within five(5) days after payment is due per contract shall constitute a material breach of this Agreement. All legal,court or otherwise collection cost incurred by Contractor are to be paid by Customer. LABOR AND MATERIALS: Contractor agrees hofurnish the materials for the project and complete the work 0obodone inu workmanlike manner. All materials furnished under this Agreement shall be construction grade and meet industry standards. Where brand names have been specified, Contractor may at his option select substitutes when such substitutions are due to unavailability or previously specified. Contractor shall pay all subcontractors, laborers,and material suppliers, unless specified differently in writing. SPECIAL CONSIDERATIONS: For those selections of materials ih special considerations including,but not limited kn cash deposits to insure their production, Contractor may at his option require Customer to pay such required deposits directly to distributor or manufacturer rendering such services. It is understood that when matching existing conditions such as color,size, planes and texture, Contractor will provide materials so as to match, as closely as possible,the existing materials. However Contractor does not guarantee materials will match existing conditions. DISCLAIMED WORK: No soiltood ing, plan design or engineering are included in this Agreement unless expressly specified. � Contractors shall not oeheld responsible for any existing violations v/applicable building regulations o/ ordinances,whether cited"x the appropriate authority ornot. Contractor is not responsible for any abnormal or unusual pre-existing conditions including, but not � limited to,damage caused by termites or dry rot,filled ground or ground of inadequate bearing capacity, rock and other material not .. ..,.~..-/ ordinary_ hand tools,inadequate electrical wiring~ ' �� hortho|oadimpoaodbytheworkunderthiaAgnmmont.and � � plumbing, gas,waste and waterlines not shown on documents or plans furnished by Customer. Correction ofany such violations nr � abnormal conditions byContractor shall be considered additional work. ADDITIONAL WORK: Contractor shall promptly notify Customer of any additional requirements necessary to facilitate the project's � completion. Any additional work required or ordered by Customer(or any regulatory agency having jurisdiction over the project) U be set forth in a signed change order, and the agreed price shall become due and payable as agreed upon between Contractor and Customer, or within 30 days if not specified, payment is due in full. Contractor, his employees,subcontractors and agents are unauthorized to perform any additional work or to enter into any agreement to perform additional work unless agreed to in writing by Customer and Contractor through a properly executed change order,which shall become an integral part of this Agreement. PROPERTY RIGHTS AND RESTRICTIONS: Customer represents that he owns the propertydesohbed as"property address", or has authority to order and sign for work. Customer shall locate and point out the boundary lines of the property to Contractor. Customer shall be solely responsible for accuracy of markers and boundary lines indicated to Contractor and as detailed on plans and specifications approved by Customer. If a land survey is required for any reason to confirm markers or boundary lines, Customer agrees to pay for such survey. Prior to the start of construction, Customer shall give Contractor a copy of any restrictions,easements or rights of way relating to the property. ACCESS AND FACILITIES: Customer agrees to provide free access to work areas for workers and vehicles, and to provide areas to store materials and debris. Unless otherwise specified,all water,sewer,gas and electric utilities from the servicing agency to the point of entry at Customer's property line(or to the metering device if such devices are required) are the responsibility of the Customer. Customer agrees, atCustomer's 0oprovide electricity atthe project site as may berequired byContractor toeffect the work described herein incompliance with federal,state and/or provincial |mw. Contractor shall not beheld liable for minor damage tocurbs, driveways,walks, patios, unless caused bythe gross negligent movement ofworkers,vehicles, equipment, materials ordebris. START, DELAY AND COMPLETION OF WORK: Contractor agrees to commence db andtnh to worki timely fashi as to insure the project's consistent development and ultimate completion. Contractor is bound by the terms and conditions regarding start of work imposed by any licensing or regulatory agency having jurisdiction over the project. Contractor shall not be held responsible for project delays caused"acts of God,"civil unrest, acts of Customer or Customer's agent, inclement weather,strikes, labor disputes, material shortages,licensing or regulatory agency inspections,or any other actions or causes beyond the Contractor's � control. CANCELLATION CLAUSE: Option of Customer to terminate contract in the event of Contractors failure to complete work. If the Contractor shall refuse to or fail to perform the work with such diligence and force as specified in this contract, or shall fail to complete said work in a timely manner,or if Contractor does not perform the work in a professional manner according to industry standards, Customer reserves the right to give written notice to the Contractor of its intention to terminate this contract unless said violations of the specifications are corrected within fifteen (15)working days after serving ofsaid notice. |fafter fifteen(15)working days the violations correctedhave not been or satisfactoryarrangements for the completion thereof ad this contract may, atthe option cf the Customer, actions by the customer to circumvent, interrupt or otherwise,any relationship with a subcontractor and the Company. Contractor's option to terminate will be immediate and communicated in writing. DAMAGE AND INSURANCE: Contractor agrees to carry worker's compensation and business liability insurance to insure the Customer against damages or defects caused by Contractor, his employees, or any agents acting in his behalf. A valid insurance certificate will be furnished upon request. MISCELLANEOUS: Contractor may subcontract all or any portion of the work and may assign this Agreement to another Contractor, provided such assignment shall not affect the rights and privileges of Customer under this Agreement. In case one or more of the provisions of this Agreement or any application thereof shall be invalid, unenforceable or illegal,the validity, enforceability and legality of the remaining provisions and any other application thereof shall not in any way be impaired thereby. If any legal action shall be instituted to interpret or enforce this Agreement,the prevailing party shall be entitled to recover all litigation costs, including reasonable attorneys'fees. It is agreed that this Agreement shall be governed by, construed,and enforced in accordance with the laws of the State of Massachusetts. CONTRACT ADJUSTMENTS: In the event of an unanticipated increase in the cost of fuel or materials used by Northeast Contracting Solutions, Inc., reserves the right to pass through to the Customer such increases or, if the Customer does not agree to pay any such increases,to terminate the contract. LIMITED WARRANTY: Northeast Contracting Solutions guarantees workmanship,subject to the following conditions. • Contractor warrants all labor and material for a period of thirty(30)days from the date of completion of work, unless otherwise stated or an Extended Warranty is purchased. This limited standard warranty extends only to Customer and is not transferable. • Contractor will provide replacements as stated above on a one-time basis only at the request of the Customer, at no charge to the Customer except for supportive materials deemed necessary and labor. Please note, however, that Contractor is not liable under this limited standard warranty for actual of consequential damages resulting from "acts of God,"excessive weather conditions(extreme cold/drought, washouts, etc.),soil conditions, abuse,vandalism, poor drainage,salt damage. • Any warranties given by manufacturers pertaining to materials used by Contractor in with the project will be passed through and inure to the benefit of the Customer. • There is no implied warranty of merchantability or any implied warranty of fitness for any particular purpose. There are no warranties either express or implied beyond the description within this section. If you have any questions,call your salesperson for more information. Payment Schedule-Third upon acceptance, 2"d third at initiation of job, and remainder due upon completion. Change orders invoices to be paid upon completion of that change orders description of work. Accepted: The signatures below indicate that the above prices, specifications and conditions are satisfactory and hereby accepted. Payment will be made as outlined above. � f ` ( / 9'`4.Z�°",�'� .r,t"r" Dater ,.,_. r " Signature ' Client Initials AGREEMENT FOR CONSTRUCTION SERVICES BETWEEN THE NORTH ANDOVER HISTORICAL SOCIETY AND NCS,Inc. THIS AGREEMENT made this 3rd day of September, 2015 between NCS, Inc., a Massachusetts company with a usual place of business at 314 Clark Street,North Andover, MA 01845, hereinafter called the"CONTRACTOR," and the North Andover Historical Society, acting by its Agent, with a usual place of business at 153 Academy Road,North Andover, MA 01845, hereinafter called the OWNER The CONTRACTOR and the OWNER, for the consideration hereinafter named, agree as follows: 1. Scope of Work The CONTRACTOR shall perform the work set forth in the drawings by TTI Environmental, Inc., issued July 21, 2015, listed under Exhibit A, and the contractors Scope of Services proposal listed under Exhibit B. The Contractor agrees to submit a certificate of insurance and a construction schedule prior to the execution of this agreement. 2. Contract Price The OWNER shall pay the CONTRACTOR for services rendered in the performance of this Agreement, subject to any additions and deductions provided for herein. The amount to be paid to the CONTRACTOR shall not exceed One hundred eight Thousand five hundred and thirty dollars ($108,530)without the prior written consent of the OWNER. See Exibit B—Scope of Services for Summary of Cost Allowances. 3. Commencement and Completion of Work A. This Agreement shall commence upon notice to proceed by the OWNER and shall expire upon completion of the Scope of Work, unless terminated sooner in accordance with this Agreement. B. Progress and Completion: CONTRACTOR shall commence work promptly upon execution of this Agreement and shall prosecute and complete the work regularly, diligently and uninterruptedly at such a rate of progress as will insure completion in a timely manner. 4. Performance of the Work The CONTRACTOR shall supervise and direct the Work, using his best skills and attention,which shall not be less than such state of skill and attention generally rendered by the engineering/design profession for projects similar to the Project in scope, difficulty and location. A. Responsibility for the Work: (1) The CONTRACTOR shall be responsible to the OWNER for the acts and omissions of his employees, subcontractors and their agents and employees, and other persons performing any of the Work under a contract with the CONTRACTOR. Consistent with the standard of care referenced in paragraph A. above, the CONTRACTOR shall be responsible for the professional and technical accuracy for all work or services furnished by him or his consultants and subcontractors. The CONTRACTOR shall perform his work under this Agreement in such a competent and professional manner that detail checking and reviewing by the OWNER shall not be necessary. (2) Neither the OWNER's review, approval or acceptance of, nor payment for any of the work or services performed shall be construed to operate as a waiver of any rights under the Agreement or any cause of action arising out of the performance of the Agreement. B. Compliance With Laws: In the performance of the Work,the CONTRACTOR shall comply with all applicable federal, state and local laws and regulations, including those relating to workplace and employee safety. 5. Payments to the Contractor A. Payment Schedule to be as follows: $35,000 within(15) days of invoice for initial mobilization of equipment and delivery of materials. $35,000 within(15) days of invoice for completion of approximately 65%of scope of work. Final payment less 10%within (15) days of invoice for substantial completion, including reconciliation of Budget Allowances. Final balance within (15) days of invoice for completion of Punchlist items. B. If the OWNER authorizes the CONTRACTOR to perform additional services,the CONTRACTOR shall be compensated in an amount mutually agreed upon, within two weeks of the completed work, unless otherwise agreed to. Except in the case of an emergency, the CONTRACTOR shall not perform any additional services until such compensation has been so established. 6. Final Payment,Effect The acceptance of final payment by the CONTRACTOR shall constitute a waiver of all claims by the CONTRACTOR arising under the Agreement. 7. Terms Required By Law This Agreement shall be considered to include all terms required to be included in it by the Massachusetts General Laws, and all other laws, as though such terms were set forth in full 2 herein. 8. Indemnification A. General Liability: The CONTRACTOR shall indemnify and hold harmless the OWNER from and against any and all claims, damages, losses, and expenses, including attorney's fees,to the extent arising out of the performance of this Agreement and to the extent the same relate to matters of general commercial liability,when such claims, damages,losses, and expenses are caused, in whole or in part, by the negligent or wrongful acts or omissions of the CONTRACTOR or his employees, agents, subcontractors or representatives. 9. Insurance A. The CONTRACTOR shall at his own expense obtain and maintain a Contractor's General Liability Insurance policy for errors, omissions or negligent acts arising out of the performance of this Agreement in a minimum amount of $1,000,000.00. B. The coverage shall be in force from the time of the agreement to the date when all construction work for the Project is completed and accepted by the OWNER. If, however,the policy is a claims made policy, it shall remain in force for a period of six(6)years after completion. Since this insurance is normally written on a year-to-year basis,the CONTRACTOR shall notify the OWNER should coverage become unavailable. C. The CONTRACTOR shall, before commencing performance of this Agreement, provide by insurance for the payment of compensation and the furnishing of other benefits in accordance with M.G.L. c.152, as amended, to all its employees and shall continue such insurance in full force and effect during the term of the Agreement. D. The CONTRACTOR shall also maintain public liability insurance, including property damage, bodily injury or death, and personal injury and motor vehicle liability insurance against claims for damages because of bodily injury or death of any person or damage to property. E. Evidence of insurance coverage and any and all renewals substantiating that required insurance coverage is in effect shall be filed with the Agreement. Any cancellation of insurance, whether by the insurers or by the insured, shall not be valid unless written notice thereof is given by the party proposing cancellation to the other party and to the OWNER at least fifteen days prior to the intended effective date thereof, which date shall be expressed in said notice. 3 10. Notice All notices required to be given hereunder shall be in writing and delivered to, or mailed first class to,the parties'respective addresses stated above. In the event that immediate notice is required, it may be given by telephone or facsimile, but shall,to the extent possible,be followed by notice in writing in the manner set forth above. 13. Termination A. Each party shall have the right to terminate this Agreement in the event of a failure of the other party to comply with the terms of the Agreement. Such termination shall be effective upon seven days'notice to the party in default and the failure within that time of said party to cure its default. B. The OWNER shall have the right to terminate the Agreement without cause,upon ten(10) days' written notice to the CONTRACTOR. In the event that the Agreement is terminated pursuant to this subparagraph, the CONTRACTOR shall be reimbursed in accordance with the Agreement for all work performed up to the termination date. 14. Miscellaneous A. Governing Law: This Agreement shall be governed by and construed in accordance with the law of the Commonwealth of Massachusetts. IN WITNESS WHEREOF, the parties hereto have set their hands and seals,the OWNER by its authorized representatives who, however, incur no personal liability by reason of the execution hereof or of anything herein contained, as of the day and year first above written. North Andover Historical Society: By: By; _ .. . .. � _. CONTRACTOR Name: %' Type or P int Name: c ✓ ., f Q C.6 1 ,�fr��''-:��(:'��`�%I�._ Type or Print Title: Title:' Cin ' M Date: ' L'o t Attachments: 4 EXIBIT A -Drawings by TTI Environmental, Inc., issued July 21, 2015 EXIBIT B -NCS, INC. Scope of Services EXIBIT B — SCOPE OF SERVICES The following items are a summary of scope of services associated with this contract: Dig along foundation and expose along entire rear of building, as determined by plan date 7-21-15. Remove slab concrete on rear doors and replace in similar size in granite. Remove wall along Academy Road to create and facilitate work area and reinstall with additional 10' 45 degree angled wall, then graded to support soil again. Power wash and prep exterior of basement to allow waterproofing to reduce water infiltration. Provide spray foam and Waterproofing at exposed existing stone foundation walls. Install drainage pipe per plan and tie in downspouts as indicated. Back fill and compact as per plan. Clear, cut and grade rear of building in preparation for new New England field stone wall. Install new slab for new wall, install wall and install drainage behind per drawing. Install friable loam in damaged areas, grade, roll and seed all disturbed areas. Provide Atrium Domes for four basement windows. The following allowances are included with the contract price: Install new gutters, down spouts and leaf guards to replace existing, Drip extensions, wedges, roof hangers, with 3 valley guards And 9 drain caps, fascia(I8') removal of old gutters (will need further discussion and review) Budget Allowance $4250 Remove and install 510 bit Conc. Walk Budget Allowance $8500 Repair sump pipe w/associated asphalt patchwork. Budget Allowance $7500 Cost of Building Permit. Budget Allowance $1500 Total Budget $108,530 5 Northeast Contracting Solutions, Inc. Invoice 314 Clark Street North Andover, MA 01845 Date Invoice# 9/3/2015 41339 Bill To North Andover Historical Society 1.53 Academy Lane North Andover,MA 01845 P.O. No. Terms Project Net 10 Days Quantity Description Rate Amount RE: 153 Academy Road,North Andover,Mass. Construction Work as per Attached Agreement Dated 9/3/15: 108,530.00 108,530.00 1st INSTALLMENT DUE WITHIN(15)DAYS: $35,000.00 Total $108,530.00 Payments/Credits $0.00 Balance Due $108,530.00 Phone# Fax# 978-685-0568 978-794-3780 Applicant '�nfoCrrtatlon Prepared on 05/21/2015 Page 2 of 5 agency: MTM Insurance Associates For: Northeast Contracting Solutions Inc 1320 Osgood Street 314 Clark Street North Andover,MA 01845 North Andover,MA 01845 (978)681-5700 Bus: (978)794-1010 (978)681-5700 larmstrong@nlcinc.net lauriem@mtminsure.com www.mtminsure.com Applicant Inforrrtation Arrount/Limits Insurance GomoanV !iiPolicy Number Policy Period Premium First Named Insured: Northeast Contracting Travelers Insurance Company 7PJUB8D88464915 1/7/2015-1/7/2016 Solutions Inc These schedules are provided as a brief outline of your policy. You must refer to the provisions found in your policy for the details of your coverages,terms,conditions and exclusions that apply. S,Urnmar Of I IISUranCe .o....r..e.pared on: o5lzvzol5 . Page 3 ot5 y agency: MTM Insurance Associates For: Northeast Contracting Solutions Inc 1320 Osgood Street 314 Clark Street North Andover,MA 01845 North Andover,MA 01845 (978)681-5700 Bus: (978)794-1010 (978)681-5700 larmstrong@nlcinc.net lauriem@mtminsure.com www.mtminsure.com Coverage Arriount/Llmlts Insurance ComoanV. Polity Number Policy Period Premium Ullorker5 Compensation Travelers Insurance Company 7PJUBSD88464915 117/2015 1/7/2016 Part 1-Workers Compensation States: MA Part 2-Employers Liability: WC&Employer's liability Each Accident Limit:= 500,000 Disease Policy Limit:?' 500,000 Disease Each Employee: 500,000 Deductible: Deductible Type: Applies To: Other Coverages: State surcharge 1 Expense constant Increased employer's liability TERR Experience Mod Factor 1 ADDA FOR MIN PREM EMPLOYERS LIAB INC LMI Part 3-Other States Included: Part 3-Other States Excluded: These schedules are provided as a brief outline of your policy. You must refer to the provisions found in your policy for the details of your coverages,terms,conditions and exclusions that apply. i PQ(iCy C7vervleW Prepared on: 05121/2015 Page 1 of 5 agency: MTM Insurance Associates For: Northeast Contracting Solutions Inc 1320 Osgood Street 314 Clark Street North Andover,MA 01845 North Andover,MA 01845 (978)681-5700 Bus: (978)794-1010 (978)681-5700 larmstrong@nlcinc.net lauriem@mtminsure.com www.mtminsure.com Policy Type Insurance Company Policy Number Policy.Perlod Total Cost Workers Compensation Travelers Insurance Company 7PJUB8D88464915 1/7/2015-1/7/2016 877.00 3 i i s i f t i J s 3 These schedules are provided as a brief outline of your policy. You must refer to the provisions found in your policy for the details of your coverages,terms,conditions and exclusions that apply. Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 167900 Type: Private Corporation Expiration: 11/17/2016 Tr# 258009 NORTHEAST CONTRACTING SOLUTIONS NORMAN LEE 314 CLARK ST N. ANDOVER, MA 01845 Update Address and return card.Mark reason for change. SCA 1 20M-05/11 Address [] Renewal [:] Employment E] Lost Card c�/!ae�anznaa�zcueall�a�C��r�atJac�utelL`.� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only LfOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 167900 Type: Office of Consumer Affairs and Business Regulation xpiration 11/17/2016 Private Corporation 10 Park Plaza-Suite 5170 B ston,MA 02116 NORTHEAST CONTRACTING SOLUTIONS INC. i :/ NORMAN LEE 314 CLARK ST N.ANDOVER, MA 01845 Undersecretary Not valid without ignature The Commonwealth of Massachusetts Department oflndustrialAccidents -:gal.. n..:.r i 1 Congress,street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FII,ED WITH THE PEPJVH TING AUTHORITY. Applicant Information Please Print Le ibl NaMe (Business/Organization/Individual): NOA Address: �'� c, City/State/Zip: AJVUV MA- t�rvl> Phone#: °1^1�- �a�� 6 Are you an employer?Check the appropriate box: Type of project(required): 1.gIamaemployer with employees(fun and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 []Building 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.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hors on hired the sub-contractlisted the attached sheet. g. 13. re airs • These sub-contractors have employees and have workers'comp.insurance.# Roof 6.F1 We are a corporation and its off-rcers have exercised their right of exemption per MGL c. 14. Other 152,§1(4),and we have nq employees.[No workers'comp.insurance required.] C1l n 1 *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 indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conlraci&s have employees,&y must provide their workers'comp.policy number. -tam an employer•that is providing workers'compensation insurance for•my employees.'Below is the policy and job site information. Insurance Company Name: r I wR V/s (Ur-I Ir Q Policy#or Self-ins.Lie.#: _-TP ) 0T?,T5 1.>�S Ts��W ( � Expiration Date: Job Site Address: ; y V d p Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 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 coverage ver] ation. Ido hereby e n r pat Up VIdes of per;jury that the information provided above is true and correct. Signature: Date: Phone# IOff —0 S�t� Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-104241 Construction Supervisor MARK DELGRECO 2 FOX HOLLOW ROAD r DERRY NH 03038 - � 4 �-nn l� Expiration: Commissioner 08/18/2017