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HomeMy WebLinkAboutBuilding Permit #1043-2016 - Exception 4/5/2016 V (iy BUILDING PERMIT TOWN OF NORTH ANDOVER 4 ° APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received T41D Date Issued: 5/-' 45-//,(4 �SsgCHU IMPORTANT:Applicant must complete all items on this page LOCATION �dC� 4r'.ry4✓� _ Print PROPERTY OWNER 1i1 lI e�dG,r U is t> Print MAP NO: _90VJ PARCELCh& ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: Xcommercial X.Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well 0 Floodplain Wetlands Watershed District u Water/Sewer o v Z e - o_6v fit, ``Identific/ation Please Type or Print Clearly) OWNER: Name: 46�- , �il►ovo;- aU,�}t-y C�.1✓ Phone: Address: cao or-e-14 Loal CONTRACTOR Name:x'04 ker ,Jr P z . Phone: 9 79 50-0 53 C::� ��L_ C, Address: A _ y+ C't fl Vim'�'1 r Supervisor's Construction License: Exp. Date. 05 1, 40 1 Home Improvement License: Exp. Date ARCHITECT/ENGINEER Phone: Address: Reg. No. `7 FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ glo,_ FEE: $ 907. — - Check 07. — Check No.: gammig <�,�7-/ Receipt No.: 30 ;P-613 NOTE: Persons contracting with unre We contractors do not have access to the guara fund ignature of Agent/Owner Signature of contractor Location �> C .t4fA. r � No. /1641' ^ '2 Date A"- 0 - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ; q, t� Y Check# I :JJ203Building Inspector K O� NORTHI q BUILDING PERMIT TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received �gssgcHus���5 Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER 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 ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑:Septi ❑1Nell I`. ❑IFlood lain, Wetla _ds 4 ❑ 41Naterhed District_ . LF 1 ,ateWS! ef, - - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp., Date: Home Improvement Licenser Exp. Date: ARCHITECT/ENGINEER Phone: No. Y Address: Reg. - FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ` Sianat �r of cortra�to�' f �:�- - --- Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. i Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products it i OTE: All dumpster permits require sign off from Fire Department prior to Issuance of Bldg Perm .Addition Or Decks 4. 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) a. Building Permit Application 4 Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses � Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code 4� Engineering Affidavits for Engineered products Permit OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. 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 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning(Massage/Body Art ❑ FFoodPackagging/Sales ools ❑ Well ❑ Tobacco Sales ❑ ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signafiure_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed ori Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes Planning Board Decision: Comments A ,,Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEP,4RTMENT -,Temp Dumpster o' sit yes Located at 1.24 Main Street Fire Departmen signa ure/date +, 9 r d R , .. v "sem a "t ; • t ,a �` 1 COMMENTS . @...�•4!Priw ter�!f�:s ^`+^'+>^;�•rd-.:w.CCl�rw.C:...iyL,.L..iS�'riS"iC�:'>wics� C O Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For.department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 1 NORTH "q . � . W. I . . _ ic ve- _ 0 Wt . . waddllkt. 0 AMER ' � ' t -0 No. Ibili ,� 2.6;;N-� h ver, Mass - c0c.NICNlw.c.c 1• � ,o ��. qS RAreo fJ BOARD OF HEALTH Food/Kitchen PERM- IT T LD Septic System w J�,/ i BUILDING INSPECTOR THIS CERTIFIES THAT ............. � :�....: �1.�I..4.C!�:::. .a::.. . .. ��./: ..:.................:.................... �� y, /02 has permission to erect .......................... buildings on ......:� 6 Foundation...............�.�.��l.r�..lyl..�....................... Rough tobe occupied as .............. ... .. ......................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file.in.this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS Rough Service ..................... ..... .. ............ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. � r Bunker Building & Remodeling, LLC Home Improvement Contract THIS CONTRACT is entered into on this 5TH day of March 2016,by and between North Andover Country Club/Stephen Kohr (hereinafter"Owner")having an address of 500Great Pond Road North Andover MA. and Bunker Building& Remodeling, LLC (hereinafter"Contractor"),having an address of 6 Glendale Street, Haverhill,Massachusetts, 01832,Massachusetts Registration Number 104908. Whereas the Owner desires to engage the Contractor to perform certain work on the premises located at 500 Great Pond Road North Andover MA. ("premises"), whereas the Owner desires to rehabilitate,renovate,remodel and/or improve the aforesaid premises in accordance with local and state building codes,and whereas the Owner agrees to compensate Contractor for services performed and materials provided, Now,therefore,the parties to this Contract mutually agree as follows: 1. Scope of Work The Contractor shall perform the proposed improvements specified in the plans and/or specifications developed for this project, including materials to be utilized, attached hereto as Exhibit A. The Contractor acknowledges that the proposed improvements have been reviewed and that said improvements are accurate and consistent as to scope of work and the cost for said improvement. The Contractor agrees that it shall use materials consistent with industry standards in the performance of said contract. 2. Time for Performance The Contractor shall commence the work to be performed under this Contract by a date to be determined by both parties or as soon thereafter as a building permit is received. The Contractor acknowledges that time is of the essence in the performance of the Contract. The work shall be substantially completed by no later than sixty days plus or minus from the starting date,barring any unforeseen complications "Substantial completion" is defined as being the point at which the project is suitable for its intended use, or the issuance of a final building department approval, whichever occurs first. The parties agree that time shall be reasonably extended for substantial completion and final completion if it is determined that there was an excusable delay, including but not limited to strikes,acts of god, Owner's failure to comply with the terms of the contract or other reasons beyond the control of the Contractor. The Owner acknowledges that change orders will add extra contract days to the project schedule. 3. Responsibilities of the Contractor (A) Insurance Contractor certifies that it carries adequate insurance to indemnify the homeowners. All insured subcontractors have Certificates of Insurance on file with Contractor. (B) Warranties The Contractor shall furnish Owner with all warranties from all manufacturers. The Contractor extends a one(1)year limited warranty against defective materials and/or workmanship. That one (1)year warranty shall run from the date of substantial completion of the work on the project. No warranty is provided by Contractor for any materials furnished by Owner for installation. No warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor within the dwelling and the Contractor specifically does not provide any warranty that existing/used materials will not be damaged during the removal and reinstallation process. One year after substantial completion of the project,the Owner's sole remedy is with the manufacturer,not with Contractor. Repair of the following items is specifically excluded from Contractor's warranty: damages resulting from lack of Owner maintenance, damages resulting from Owner abuse and/or ordinary wear and tear, deviations that arise such as the minor cracking of concrete, stucco and plaster, minor stress fractures in drywall due to the curing of lumber, warping and deflection of wood, shrinking and cracking of groups and caulking, fading of paints and finishes exposed to sunlight. (C) Permits and Codes The Contractor agrees to secure all necessary permits and licenses required for the Contractor's performance. The specific permits that will be necessary for this project are: Building, Plumbing and Electrical. The Owner acknowledges that homeowners who secure their own permits are excluded from the guaranty fund provisions of the Home Improvement Contractors Law, Massachusetts General Laws Chapter 142A. 2 (D) Materials and Labor The Contractor shall furnish all material,machinery,tools, equipment, services, labor and supervision for the project,unless otherwise provided by a subcontractor, independent contractor or otherwise agreed to in writing. (E) Premises The Contractor will keep the premises clean and orderly as reasonably possible during the course of work and shall remove all debris at the completion of the work, with the exception of any hazardous materials. Hazardous materials, if any, shall be removed by an agent of Owner. Materials and equipment that have been removed and replaced as part of the work performed shall belong to the Contractor. (F) Inspection The Contractor will cooperate with any inspector given access to the project by Owner. (G) General The Contractor will supervise and direct the work on said premises, using his skill and attention. The Contractor will be solely responsible for all construction means, methods,techniques, sequences, and procedures and for coordinating all portions of the work under the Contract. The Contractor will use reasonable efforts to employ only qualified persons properly skilled in the tasks assigned. The Contractor shall be responsible for the acts and omission of all its employees and subcontractors,their agents and employees and all other persons performing any of the work under a contract with this Contractor. This paragraph does not bar the Contractor's right to seek contribution and/or indemnification from any subcontractor or independent contractor. The Contractor, at the completion of the work,will remove all his waste materials and rubbish from and about the premises as well as its tools, construction equipment, machinery and surplus materials as soon as practicable. 3 P 4. Responsibilities of Property Owner (A) Utilities The Owner shall permit the Contractor to use existing utilities, including but not limited to light,heat,water, and electricity, at no cost to Contractor,when necessary to perform or complete the work. (B) Facilitation of Work The Owner shall cooperate with the Contractor to facilitate the performance of the work. (C) Payment The Owner shall be responsible for making prompt progress payments as payments become due, according to the schedule set forth at Exhibit B. Payment for change orders is due in full at the time the change order is approved by Owner. Payment for change orders is the sole responsibility of Owner and will not affect the payment plan set forth at Exhibit B. Payment for special order items is due in full upon order of each item. (D) Duty with Respect to Warranties If a manufacturer has provided a warranty with regard to a product used to complete the work,the Owner agrees to exhaust his remedies first with the manufacturer for any problems with that product. Only if the manufacturer has provided written denial of coverage under the warranty may the Owner seek redress against Contractor. However,by virtue of this paragraph, Contractor does not agree to assume liability. If a subcontractor or independent contractor has provided a specific warranty with respect to work performed by that subcontractor,the Owner agrees to exhaust his remedies first with the subcontractor or independent contractor for any deficiencies with that work. Only if the subcontractor has provided written denial of coverage under the warrantymay the Owner seek redress against the Contractor. However,by virtue of this Y g paragraph, Contractor does not agree to assume liability. Within 48 hours of discovering any alleged defect,the Owner agrees to notify the Contractor in writing of any alleged defects, whether within the scope of any warranty or whether outside the scope of any warranty. If said defects are within the scope of any warranty,the Owner shall provide Contractor a reasonable opportunity to remedy any defect and mitigate damages accordingly. 4 5. Compensation The Contractor proposes to furnish all the material and do all the work described in Schedule A to this Contract for the sum of Nine Thousand Four Hundred Forty Nine and 00/100. The Owner agrees to pay the Contractor this amount for performance of the work. 6. Payment Schedule Payment shall be made in accordance with the schedule set forth at Exhibit B attached hereto and incorporated herein. Acceptance of final payment by Contractor, including any payment for change orders, shall constitute a representation by the Contractor that any mechanics liens and or materialman's liens arising from said Contract have been or will be timely released and/or discharged and that all subcontractors and suppliers have been paid in full for labor and materials provided. Said representation shall not take effect until the final payment has actually been received by Contractor. If final payment is made by check,this shall occur upon posting of the check to Contractor's account. If final payment is made by cash,this shall occur upon Contractor's receipt of payment. It is understood and agreed that bills are due and payable in full at the times listed on the payment schedule attached as Exhibit B. The Owner agrees to pay a finance charge of 1.5%per month(annual percentage rate of 18%)on any unpaid balance. All costs and expenses of collection, including but not limited to reasonable attorneys'fees, shall be paid by Owner should collection procedures be instituted. If Owner should fail to make a payment in accordance with the schedule attached as Exhibit B, Contractor has the option to cease work on the project until payment is made. The total number of days that work is stopped due to a late payment by Owner shall be added on to the completion date for the project set forth in paragraph 2. 7. Provisions of the Home Improvement Law The provisions of the Home Improvement Contractor Law, Massachusetts General Laws Chapter 142A, apply to this Contract. The Contractor refers the Owner to the provisions of that Act. (A) Registration The Contractor is registered with the Administrator of the Board of Building Regulations and Standards, an agency within the Executive Office of Public Safety and any inquiries regarding the Contractor relating to a registration should be addressed to the 5 Administrator. All contractors and subcontractors must be registered by the Administrator. The Contractor's registration number is 104908. (B) Cancellation Rights The Owner has a three day cancellation right under Massachusetts General Laws Chapter 93, Section 48, Chapter 2551), Section 14, or Chapter 1401), Section 10 as may be applicable. The Owner may cancel this contract without penalty or obligation within three business days of the date of the contract. If the Owner cancels this contract within three business days of the date of the contract, any payments made by Owner under the contract will be returned within ten(10)business days following receipt by Contractor of the cancellation notice. If Owner cancels this contract within three business days of the date of the contract, Owner must make available to the Contractor, in substantially as good condition as when received, any goods or materials delivered to Owner under this Contract. If Contractor does not pick them up within twenty days of the date of cancellation pursuant to this paragraph, Owner may retain or dispose of the goods or materials without further obligation. If Owner does not make the goods or materials available to the Contractor or if Owner agrees to return the goods or materials to Contractor but fails to do so, Owner remains liable for performance of all of the obligations under the contract. To cancel this contract pursuant to this provision,the Owner must mail or hand- deliver a signed and dated copy of a cancellation notice not later than midnight of the third business day following the date of this contract. (C) Liens To the Contractor's knowledge, as of the date of the execution of this Contract, there are no liens or security interests on the residence as a consequence of this Contract except for any lien as provided for by the mechanics lien statute. Contractor may file a mechanics lien on the property if desired. In the event that it becomes necessary for the Contractor to file a mechanics lien on the property as security for payment from the Owner or an attachment of real estate, Owner agrees to be responsible for the costs and legal fees associated with perfecting that mechanics lien and/or attaching said real estate. (D) Acceleration of Contract No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure. However,where the contractor deems himself to be insecure,he may require as a prerequisite to continue said work that the balance of funds due under the 6 contract,which are in possession of the owner, shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawal. 8. Alternative Dispute Resolution Any controversy or claim arising out of or related to this Contract involving an amount which is equal to or less than the dollar limit of the Small Claims Court shall be heard in the Small Claims Division of the District Court in Haverhill, Massachusetts. Any controversy or claim arising out of or related to this Contract which is over the dollar limit of the Small Claims Court must be settled by binding arbitration administered by the American Arbitration Association in accordance with the Construction Industry Arbitration Rules,unless the parties agree to some other arbitration or arbitrator. Judgment upon the award may be entered in any Court having jurisdiction thereof. The parties agree that arbitration shall be the sole and exclusive remedy for any controversy or claim arising out of or related to this Contract, except that the Contractor may file the necessary documents with the egistry of Deeds and/or applicable Court to secure and/or perfect a mechanics lien pe ing resolution of the arbitration. Contractor's Initials wner's Initials 9. Modifications (A) Necessity of Writing It is agreed by the parties that no modifications may be made to this contract unless the modification is in writing and signed by both parties. (B) Concealed or Unforeseeable Conditions This Contract is based solely on the observations Contractor was able to make with the structure in its current condition at the time this Contract was bid. If additional concealed or unforeseeable conditions are discovered once work has commenced which were not visible or foreseeable at the time this proposal was bid, Contractor will stop work and point out these unforeseen and/or concealed conditions to Owner so that the Owner and Contractor can execute a change order for any additional work. (C) Deviations from Scope of Work; Change Order Any alteration or deviation from the scope of work referred to in Exhibit A involving extra cost of materials or labor will be executed upon a written change order issued by Contractor and should be signed by Contractor and Owner prior to the commencement of additional work by Contractor. 10. Applicable Law 7 This Contract shall be governed by the laws of the Commonwealth of Massachusetts. 11. Merger This Contract,together with the exhibits attached,represents the entire understanding of the parties, and neither party is relying on any representation not contained herein. 12. Severability In the event that any provision of this Contract shall be deemed invalid, unreasonable or unenforceable by any court of competent jurisdiction, such provision shall be stricken from the Contract or modified so as to render it reasonable, and the remaining provisions of this Contract or the modified provision as provided above shall continue in full force and effect and be binding upon the parties so long as such remaining or modified provisions reflect the intent of the parties as of the date of this Contract. No work shall begin on the premises until this contract is executed By both Owner and Contractor. DO NOT SIGN THIS FORM IF THERE ARE ANY BLANK PACES 10 r M k unker, r Dated:,3 Z //� Bunker Building&Remodeling, LLC Federal Tax ID No. 20-8362262 Dated: Owner Dated: 8 EXHIBIT A SCOPE OF WORK AND DESCRIPTION OF MATERIALS TO BE UTILIZED EXHIBIT B Remodel existing first floor ladies rest room and will include the following: 1) Remove existing two steel bathroom partition and replacing them with Hadrian LT Gray units. 2) Each to have one SS seat cover dispenser. 3) Each to have one double toilet tissue holder with shelf. 4) Each to have one feminine napkin disposal container. 5) Remove both toilet and replace with new white comfort height toilets. 6) Remove and replace existing two bowl counter and install one costume three door white vanity with granite top(no back splash),two white china under mount bowls and two chrome faucets. 7) Remove existing framed mirror and replace with a full size frameless one. ***This contract does not include the following*** Any dumpster for construction debris No permit allowance No electrical allowance. 9 PAYMENT SCHEDULE $ 3,164.00 due from Owner upon signing the contract (May not exceed 1/3 of the total contract price or the cost of special order items,whichever is greater) $ 3,164.00 due upon installation of stall partitions $ 3,162.00 due upon completion. Any and all work done above and beyond this contract shall be done on a time and material basis which will be discussed and agreed upon by both the owner and the contractor prior to the start of such work. 10 The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 ' Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Cont ctors/Electricians/Plumbers. TO BE FED WITH THE PEPMTTING A HORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: C, 6 TI 2 o 4 Le City/State/Zip: Ofl v er�1• 014 Phone#: 5.3 Are you an employer?Check the appropriate box: Type of project(required): 1.2g lam a employer with _employees(full and/or part-time).* 7. El New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling 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 [❑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..C1 Electrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � $ 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and Nye have no.employees.[No workers'comp.insurance required.] r: *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 jhat 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-con6ciors have employees,'they must provide their workers'comp.policy number. Iain an employer that is piovidiing workers'compensation insurance for my employees.•Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: fob Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 civilpen ies 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 stat eme ay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the a' s an4,,denalfles ofperjury that the informationprovidedoa/bove true a d correct. Signature: / Date: `� , �U Phone#: 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): i 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 thein;employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." ' An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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 of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any 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 been presented to the contracting authority." Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and-phone number(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 not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of IMustrial 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 the permit 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 that the 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 that must submit multiple 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 is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ACORO® DATE(MMIDDIYYYY) CCO CERTIFICATE OF LIABILITY INSURANCE 4/5/2016 ID 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(ies)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 CONT CT NAME: Katie Gregoire Sullivan Insurance & Financial, Inc. Nc : (978)372-2790 FAXNo:(978)373-2281 487 Groveland Street E-MAIL DDRSSS:kgregoire@sullivanIF.com oire@sullivanIF.com Ag INSURER(S)AFFORDING COVERAGE MAIC 6 Haverhill MA 01830 INSURERA:Preferred Mutual 15024 INSURED INSURER B Citation Insurance 40274 Bunker Building & Remodel, LLC, DBA: Mark Bunker DBA INSURER C:Travelers Indemnity Company 25658 6 Glendale Street INSURER 0: INSURER E Haverhill MA 01830 INSURER F: COVERAGES CERTIFICATE NUMBER-.CL164502812 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 TYPE OF INSURANCE A SU POLICY NUMBER POLICY M DCD EFF MOM/DD EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DA A13E A CLAIMS-MADE ❑X OCCUR PREM SES Ea occu D nce $ 50,000 BOP0100721660 2/5/2016 2/5/2017 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PECT RO a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 J OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea aaident B ANY AUTO BODILY INJURY(Per person) $ 250,000 ALL OWNED XSCHEDULED HX2140 3/3/2016 3/3/2017 BODILY INJURY(Per accident) $ 500,000 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ 100,000 $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PEROTH. Y/N AND EMPLOYERS'LIABILITY STATUTE I I ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? NIA 7PJDB-5861451-2-13 12/27/2015 12/27/2016 C (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 MS6describeunder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) General Carpentry Operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �. f Diane Fraioli/KJG � ..t..�- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD I NS025 rmm4nt i - 1 t Massachusetts Department of Public Safety t{( Board of Building Regulations and Standards License: CS-054228 , tp Construction Supervisor I m i � MARK S BUNKER 6 GLENDALE STREET_ HAVERHILL MA 01832 i _ Expiration: 0112412018 Commissioner ' V✓LG'�Oi/7Z07P092LC{2CZ t1L 0VGGCC,11lICftillf'�1.3'. j Office of Consumer Affairs&Business Regulation - ME IMPROVEMENT CONTRACTOR egistration: 104908 Type: - ! _ xpiration: :-7/15/2016 DBA MARK S. BUNKER BUILDING AND REMOLD s Mark Bunker t 6 Glendale Street 1 Haverhill, MA 01832 Undersecretary