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0023 BARNES ROAD - BPA-14-216 ROOF 2, q Cp 3 eI { The Commonwealth of Massachusetts ° Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR i Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Revised One-or Two-Family Dwelling March 2011 This Section For Official Use Only Building Permit Number: Date A plied: D q O 3 I Building Official(Print Name) ignature SECTION 1: SITE INFORMATION 1.1 Propert dress: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2��.,O� wner of Record* I .e46-,,1 Ts. kt'P � ,M1`ai�e `f �roL7/J Name(Print) City, State,ZI 11 7-3 No.and S ree—�t Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Buildin Owner-Occupie Repairs(s)K I Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ geL2#. tV 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ / 4. Mechanical (HVAC) $ List: y� 5. Mechanical (Fire ��t 1 Suppression) $ Q Total All Fees: $ Check 6. Total Project Cost: $ t7 vim '' ❑ Paid Ii Check t t Amount: n Full ❑Ouanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Numlxr Eipiration Date Name of CSL-Hot D List CST,Type(see below) lit. /�o�ef'orD T Description dress U Unrestricted(up to 35,000 Cu Ft. Restricted 1&2 Family Dwellin- Si attre M MasonryOnly 7!y ely)•/47� PS�F Residential Roolm Covering Telephone Residential Window and Sidin Residential Solid Fuel Aurnin A fiance Installation D Residential Demolition 5.2 R gistered Home Improvement Contractor(HIC) �V��� ffftCCo6mpany Name or HIC R grstrant Na e 'Regisuahon Number yam?/ / Expimtion Date Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.§ 25C(6)) Workers Compensation Insmance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building perritit. Signed Affidavit Attached? Yes A-<No ❑ Current Certificate must be on file in office Yes SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES SFFOR ' /BoUILDING PERMIT 1 i) D✓✓r✓y elV j /�1/f —r `�7 `� as Owner of the subject property hereby authorize _ e' AIC10 ) to act on my behalf. in all matters relative to work authorized by this building permit application Q Kninatukcof r/ Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION r2 1, 6 7 A 2/ZEi C A A62,G 124,p,� ,as Owner or Authorized Agent hereby declare that the statemeAts and information od the foregoing application are true and accurate,to the best of my knowledge and behalf. Prm ante I Si lure er or Authorized Agent Date _(Sigiled under the urs and �wlties ofruy NOTES: I. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program).will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 10A5.respectively. 2. When substantial work is planned provide the information below: Total floors area(Sq. Ft.) (including garage,finished basemcnt/attics.decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for"Total Project Cost" Proposal AB Carnes Inc. 30 Arrowhead farm Rd Page 1 of 1 Boxford, Ma. 01921 978-887.1431 Mass, Builders License No.000230 Contractors Registration. No 100733 Proposal Submitted To: DONNA&JOYCE TREMBLAY Date July 31, 2013 23 BARNES RD Project Name SALEM, MA 01970 Address 978-741-1594 We propose to furnish material and labor-in accordance with the specifications below: Seventy Five Hundred Dollars($7,500.00) Payment to be made as follows: $300.00 Deposit, Balance Upon Completion ' �� ' o: Notice:All home improvement contractors and subcontractors engaged in home improvement contracting, specifically exempt Authorized P 9 P Y P with the Co by provisions Signature!1 of Chapter 142A of the General Laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Note:This pro sal may be hdrawn by us if not accepted within 30 Mass.govllicenses website. days. ROOF PROPOSAL ® STRIP ROOF OF ALL LAYERS OF ASPHALT SHINGLES.COVER ROOF DECK WITH TITANIUM RHINOROOF HIGH PERFORMANCE WATERPROOF UNDERLAYMENT MEMBRANE.COVER EXTERIOR WALLS AND FOLIAGE WITH TARPS TO HELP PREVENT DAMAGE. ® INSTALL CARLISLE HIGH PERFORMANCE ICE&WATER BARRIER OVER ALL HEATED AREAS SIX FEET WIDE AT THE LEADING EDGE OF ROOF AND THREE FEET IN ALL VALLEYS&AROUND ALL ROOF PENETRATIONS. ® COVER ALL PERIMETERS WITH EIGHT INCH ALUMINUM DRIP EDGE. ® INSTALL RIDGE VENT AND/OR®AS NEEDED ROOF LOUVERS FOR ADDED ATTIC VENTILATION. �i..�'l IW Lai?- (,li//yj ® COVER SOIL PIPES WITH NEW RUBBER FLASHING BOOTS. ® REPLACE WALL FLASHING(S)AS NEEDED WITH ALUMINUM OR LEAD AT THE ADDITIONAL COST OF$25.00PLFT.WE MAY NEED TO REMOVE THE SIDING TO PERFORM THIS WORK.YOU MAY NEED TO HAVE A CARPENTER REINSTALL THE REMOVED SIDING. ® CHIMNEY FLASHING;CUT ALL EXISTING TAR AND LEAD FROM ONE CHIMNEY(S).CUT NEW REGLET WITH CARBIDE SAW AND SECURE NEW LEAD FLASHING IN PLACE W/LEAD ANCHORS. PROPERLY SEAL REGLET JOINT, PLEASE ADD$500.00 TO ABOVE PRICE ❑ REBUILD CHIMNEY FROM ROOF DECK UP WITH NEW OR USED BRICK. ADD TO ABOVE PRICE. ® COVER ROOF SURFACE WITHCERTAINTEED LANDMARK ARCHITECTURAL LIFETIME WARRANTY 240LB SHINGLES. ® REPLACE DEFECTIVE ROOF DECKING WITH 1 X8 SPRUCE BOARDS AT AN ADDITIONAL COST OF$4.50PLFT. ® COVER ROOF DECK WITH CDX PLYWOOD AS NEEDED TO REPLACE OR REPAIR DEFECTIVE DECKING,AT AN ADDITIONAL COST OF$4.00PSQFT. ® SHINGLES ARE TO BE STORM NAILED,ESSEX COUNTY BUILDING CODE REQUIRES SIX NAILS INSTEAD OF FOUR. ❑ REPLACE EXISTING SKYLIGHTS WITH NEW VELUX UNITS WITH FLASHING KITS.WE WILL PROVIDE THE SKYLIGHTS 8 FLASHING KITS AT OUR EXACT COST FROM OUR SUPPLIER,THERE WILL BE NO LABOR CHARGE IF THEY ARE THE SAME SIZE.INTERIOR WORK IS EXCLUDED. ❑ REMOVE EXISTING GUTTERS ❑INSTALL NEW SEAMLESS.032 ALUMINUM GUTTERS USING THE POSITIVE LOCKING BAR HANGER SYSTEM. ® REPLACE DEFECTIVE OR ROTTED TRIM BOARDS AS NEEDED WITH NO,2 PRIMED PINE,ADD$15.00 PER FOOT TO ABOVE PRICE. ❑ INSTALL NEW ALUMINUM DOWNSPOUTS. MECHANICALLY F AL CLEAN ALL PROJECT RELATED DEBRIS FROM OUTSIDE WORK AR .,THE PROPERTY OWNER AUTHORIZES AB CARNES,INC TO OBTAIN ALL PERMITS.WE. CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC A S. CUSTOMER SHOULD COVER VALUABLES. GREAT CARE WILL BE USED TO PR, ECT THE STRUCTURE AND FOLIAGE.HOWEVER,SOME MARRING AND OR MINNOAft GOl D'OCCl7R' SPECIAL INSTRUCTIONS: THE ABOVE PROPOSAL INCLUDES ALL ROOF SECTIONS ON PAGE FOUR OF THE EAGLEVIEW REPORT.THE LOWER FLAT ROOF OVER THE GARAGE IS EXCLUDED. SOLAR PANELS:THESE WILL NEED TO BE DISCONNECTED SO WE CAN REMOVE THEM PERMANENTLY.WE WILL REPAIR THE HOLES THAT ARE LEFT BEHIND. PLUMBER CHARLIE CASHIN(978)887-9880 UPPER FLAT ROOF:THIS WILL BE,PREPARED AS PROPOSED ABOVE THEN COVERED WITH A TWO PLY FLINTLASTIC LOW SLOPE ROOF SYSTEM. WARRANTY UPGRADE:THE CERTAINTEED WIND WARRANTY WILL BE UPGRADED FROM 110 MPH TO 130 MPH WITH AN UPGRADE TO THE HIGH PERFORMANCE HIP&RIDGE CAPS AND STARTER COURSE AT NO ADDITIONAL CHARGE.YES( ) 7V EMAIL ADDRESS:���i'\N( Warranty:All work warranted against installation defects for 5 years;this warranty is limited to the installed item(s)and its repair only.Material is warranted by the manufacturer against defects for 50 years;please see the manufacturers warranty for exact warranty performance. Cancellation:Customer has legal right under federal law to cancel this contract without penalty or obligation within four business days from the date of signing this agreement via Priority Mail Delivery Confirmation. Please see reverse side Dispute Resolution under Massachusetts Home Improvement Law 142a,All parties agree' Wince that any and all disputes relating to this proposal shall be settled by binding arbitration.This forum' dly and does not require lawyers.Plea see reverse side Ir _ N ` y�user-frtal Customer E 'ZCL ate Contractor ; C / Date 7'f Signing this Proposal means you have accepted all the term as stated on the front and back of this agreement. N Date of Acceptance ' Signatur Signature G PLEASE SEE REVERSE SIDE IMM Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcnisor License: CS-000230 BARRY s CARP1Es '�r - 30 ARROWREAD-FARM RD Boaford MA-01921` 1 - f Expiration Commissioner 03/07/2014 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100733 Type: Private Corporation Expiration: 6/23/2014 Trp 223142 A. B. CARNES, INC. t Barry Carnes 30 Arrowhead Farm Rd. Boxford, MA 01921 Update Address and return card.Mark reason for change. Address ,' Renewal Employment E Lost Card IPS-CA! 6 50M-04/04-G101216 CITY OF SALEM WASTE AFFIDAVIT As a result of the provisions of MGL Ch.40-s54, I acknowledge that as a condition of building permit# all debris resulting from the construction activity governed by this building permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL Ch.111-s150A. Waste Disposal or Solid Waste Facility: ALLIED WASTE Address: 300 FOREST ST Town/City, State, Zip: PEABODY, MA 01960 NAME OF HAULER: AB CARNES, INC. DUMP TRUCKS DATE: 9-3-2013 SIGNATURE OF APPLICANT: OP ID: SA AFRO CERTIFICATE OF LIABILITY INSURANCE DAT03113113 YY, 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 endorsements . PRODUCER 978-744-6715 NAME CT AHMED Insurance Agency,Inc. 978-741.0127 PHONE FAX PO BOX 449 INC,No,Ext): (AIC,No): Salem,MA 01970 EMAIL ADDRESS: Stephen G. PRODUCER ABCAR-1 CUSTOMER ID N: _ INSURERISI AFFORDING COVERAGE NAIC0 INS RED A B Carnes Inc - IN SURER A:ESsex Insurance Co 30 Arrowhead Farms Road INSURER e:Safety Insurance Company 33618 Boxford, MA 01921 INSURER C INSURER 0: _INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER: 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 II T R R TYPE OF INSURANCE AODL SUER POLICY NUMBER MMIDDPOLICMWI (MMIDONYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 30F9266 03/18/13 03/18114 DAMAGE TO RENTED 50roo PREMISES(Ed occurrencol S CLAIMS-MADE X OCCUR MED EXP(Anyone Pa(Sar11 S 1,00 PERSONAL B ADV INJURY 5 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000,00 X Poucv PRO LOC PD Deduct $ 50 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,00 IEe am..,c) ANY AUTO BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per acntlent) $ B _X SCHEDULED AUTOS 6213192 05/02112 05/02/13 PROPERTY DAMAGE B X HIRED AUTOS 6213192 05/02/12 05/02/13 (Per accident) $ Inc B X NON-OWNED AUTOS 6213192 05/02112 05/02113 $ UMBRELLA LIAR OCCUR. EACH OCCURRENCE S EXCESS LIAR CLAIMS MADE AGGREGATE , DEDUCTIBLE RETENTION $ S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORMARTNERF_XECUTIVE ❑ NIA E L EACH ACCIDENT' $ OFFICERIMEMSER EXCLUDED' (Mandatory in NH) E L DISEASE-EA EMPLOYEE 5 II yes,dc.cr,b.unde, DESCRIPTION OF OPERATIONSbelaw EL DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Roofing Contractor CERTIFI OLDE CANCELLATION CITYOFS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St. Salem, MA 01970 AUTHORIZED REPRESENTATIVE ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 2 ((2 9f99 The ACORD name and logo are registered marks of ACORD Berkley Massachusetts Workers' Compensation Insurance Plan Acadia Insurance Company NCCI Carrier Code 33391 Administered by Berkley Assigned Risk Services ASS N_�R(C,;SER.,'i14;-', P.O. Box 1100.Minneapolis, Minnesota 55440-1100 Phone(605)945-2144 Fax(866)215-8118 Toll Free(800)634-4589 v .berkleyassignedrisk.com CERTIFICATE OF INSURANCE 1. The Insured: WCIP Policy Number: WC-20-20-004717-00 C242 erican Construction Inc Tax ID#: F 46-1868194 elmont Street Unit 2ton, MA 02301 Policy Period: From: 412412013 To: 4/24/2014 Date of Mailing: 5/3/2013 The Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the Policy listed below. This is to certify that the Policy of Insurance described herein has 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 Policy described herein is subject to all the terms, exclusions and conditions of such Policy. TYPE OF INSURANCE LIMITS OF LIABILITY Coverage Part One State(s) Workers'Compensation Statutory MA Part Two Bodily Injury by Accident $1,000.000 each accident. Employers' Liability Bodily Injury by Disease $1,000,000 policy limit. Bodily Injury by Disease $1,000,000 each employee. Should any of the above described policies be cancelled before the expiration date thereof. notice will be delivered in accordance with the policy provisions. All Entities/Insureds: Certificate Holder's Name and Address: 1 American Construction Inc Election Election AB Carnes Inc Category Status Name 30 Arrowhead Farm Road Officer Include Manuel 3 Lema Caguan, Boxford, MA 01921 Date Issued: 5/312013 Ace Insurance Services Inc 675 Warren Ave Brockton, MA 02301 Signature_ The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth. Corporations Division ` One Ashburton Place. 17th floor Boston. MA 02108-1512 . Telephone:(617) 727-9640 Request a Certificate The exact name of the Domestic Profit Corporation: I AMFRICAN CO NS'l RI IC'TIrl1\1 INIC Entity Type: Identification Number: 00 1008 138 Date of Organization in Massachusetts: 041110011 Current Fiscal Month ! Day: 12 The location of its principal office: No. and Street: I? W A I I QTR FFT City or Town: SAL State:MA Zip: R2301 Country: I IS A If the business entity is organized wholly to do business outside Massachusetts, the location of that office: No. and Street: City or Town: State: Zip: Country: Name and address of the Registered Agent: Name: MANI [Ef I FMA-CAGI IANA No. and Street: I" WAI I SIRFFT City or Town: BROCKTON State:MA Zip 0?3l11 Country:USA The officers and all of the directors of the corporation: Title Individual Name Address(no PO Box) Expiration First,Middle, Last. Suffix Address, City or Town, State.Zip Code of Term PRESIDENT MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON.MA 02301 USA TREASURER MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON, MA 02301 USA SECRETARY MANUEL LEMA-CAGUANA 12 WALL STREET BROCKTON, MA 02301 USA DIRECTOR MANUEL LEMA-CAGUANA 12 WALL STREET >f BROCKTON, MA 02301 USA business entity stock is publicly traded: The total number of shares and par value, if any, of each class of stock which the business entity is authorized to issue: Par Value Per Share Total Authorized by Articles Total Issued Class of Stock Enter 0 if no Par of Organization or Amendments and Outstanding Nnmr_/Shares lowl Par l'alife Num cj Shams CNP $0.00000 20.000 S0.00 20.000 Consent — Manufacturer _ Confidential Data _ Does Not Require Annual Report Partnership _ Resident Agent _ For Profit _ Merger Allowed Select a type of filing from below to view this business entity filings: ALL FILINGS Administrative Dissolution Annual Report Application For Revival _ Articles of Amendment View Filings New Search Comments C 2001 -2013 Commonwealth of Massachusetts All Rights Reserved F1cln The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t' 600 Washington Street Boston, MA 02111 tvivw massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers P Please Print Leeibl� A hcant Information - Name (Business/organ zatiorJlnaividuap: A l C A X Address: 3 a A 2 A.d tAJI F AP r'"`�- A^�=4 P City/State/Zip: i i PhoJshect. pe-) /Y31 Are you an employer?Check the appropriax: Type of project(required): I am a general co I i.0 1 am a employer with 6. ❑New construction employees(full and/or art time).* have hired the su 2.❑ 1 am a sole proprietor or partner- listed on the attac7. ❑ Remodeling ship and have no employees These subcontraR. ❑ Demolition working for me in any capacity. employees and hq ❑Building addition No workers' co insurance comp. insurance.. � rap. 10.❑Electrical repairs or additions required.] 5.�4We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their t I.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12:5j�Roof repairs insurance required.] t c. 152,§1(4).and we have no 13.❑ Other employees. [No workers' comp. insurance required.] 'Any applicant that checks box at must also fill out the section below showing their workers'compensation policy infornwtion. t Flomeowmers who submit this affidavit indicating they are doing all work and then hire ourside contractors must submit a new affidavit indicating such. .Contractors Ibat check this box must attached an additional sheet showing the name of the sabcontractors and state whether or not those entities have emplovices. If the sub-contractors have employees,they must Provide their workers'comp.policy number. I am an employer that is providing workers'compensation msrtrance for my employees. Belaw is the policy and lob srh informadom Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job 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 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 or a,STOP WORK ORDER and a line of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under the ins and penalties of perjury that the information provided above is true and correct. Si nature: 7 late' Pho e#: Y 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# FORM 153 The Commonwealth of Massachusetts DIA Use Only c Department of Industrial Accidents Office of Investigations -Dept. 153 1 Congress Street,Suite 100,Boston,Massachusetts 0211.4-2017 http://www.mass.gov/dia InvestAWO ID#: AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 of the Acts of 2002 amended M.G.L. c. 15Z §1(4) by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation. Notwithstanding section 46, these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. c. 152, §1(4) as amended, I/We the undersigned officers of: AB Cames, Inc. 30 Arrowhead Farm Rd Boxford, Ma 01921 , (Name of Corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). I/We the undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L. c. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L. c. 152, §25A. I/We the undersigned have read and understand the statements and obligations as delineated above and I/we have checke he appropriate box below my/our name(s) indicating my/our desire to be exempt or not to be pt fr the provisions of M.G.L. c. 152. ed under ptW pains and penalties of perjury: - ' Barry Cames, President 04/3/2012 Si ature Print Name&Title Date(mm/dd/yyyy) ❑� wish to exercise my right of exemption or ❑ i wish NOT to exercise my right of exemption ,�� , L Anastasiya Cames, Director 04/03/2012 Signature / Print Name&Title Date(mm/dd/yyyy) ❑� 1 wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ 1 wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Signature Print Name&Title Date(mm/dd/yyyy) ❑ I wish to exercise my right of exemption or ❑ I wish NOT to exercise my right of exemption Note:ALL ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE NO MORE THAN 4 SIGNATURES. InSftctlom on back. Form 153—7/2010 MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM i The Commonwealth of Massachusetts No Fee William Francis Galvin Secretary of the Commonwealth, Corporations Division One Ashburton Place, 17th floor Boston, MA 02108-1512 r1.�'ft• T. 4�k�. Telephone: (617) 727-9640 r of the corporation: A. B. CARNES, INC. istered office address: Name: BARRY S. CARNES No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA I 3. The following supplemental information has changed: Names and street addresses of the directors, president, treasurer, secretary I 1 Title Individual Name Address (no PO Box) First, Middle, Last, Suffix Address,City or Town,State,Zip Code PRESIDENT BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA TREASURER BARRY S.CARNES 30 ARROWHEAD FARM ROAD, I. BOXFORD, MA 01921 USA SECRETARY BARRY S.CARNES 30 ARROWHEAD FARM ROAD, ( BOXFORD, MA 01921 USA DIRECTOR BARRY S.CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA DIRECTOR ANASTASIYA CARNES 30 ARROWHEAD FARM ROAD, BOXFORD, MA 01921 USA X Fiscal year end: October X Type of business in which the corporation intends to engage: GENERAL CONTRACTING &MARKETING X Principal office address: No. and Street: 30 ARROWHEAD FARM ROAD City or Town: BOXFORD State: MA Zip: 01921 Country: USA I. X its principal office _ an office of its transfer agent an office of its secretary/assistant secretary _ its registered office Signed by BARRY S. CARNES , its PRESIDENT on this 30 Day of May, 2012 I ©2001 -2012 Commonwealth of Massachusetts All Rights Reserved MA SOC Filing Number: 201287835330 Date: 5/30/2012 9:10:00 PM THE COMMONWEALTH OF MASSACHUSETTS I hereby certify that, upon examination of this document, duly submitted to me, it appears that the provisions of the General Laws relative to corporations have been complied with, and I hereby approve said articles; and the filing fee having been paid, said articles are deemed to have been filed with me on: May 30, 2012 09:10 PM WILLIAM FRANCIS GALVIN Secretary of the Commonwealth