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Home My WebLink AboutBuilding Permit #551 - 16 STACY DRIVE 1/13/2012 BUILDING PERMIT uF NORTh TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION '- Permit NO: 07 Date Received / � 4 • �• �` Date Issued: / 2 AC US . MPORTANT:Applicant must complete all items on this page r��'tr�S��.2rpi'�rrr�t.'r5.�-rG>,'.2 •.2 iii+.e _:i:r^�;sf::-''ey:z-:+a,-_ .lr - ?_ s '} j-. f-i' •'i it"� h•r.y' -4` +.Slr7 xY it -.r.- , Lr'"F ��t`.�'+ ✓t•l -z'"'..y]'+ .r C� x ..� 'i. c i,, "5. x.r tzi�`^'�G 3+_'rr ' r �c��7�- r .'r' s"rrbc a"� r-tt ��, - % .-+�}r �.-.•.+�+�. .a v-" us ._ s t: _ dK t ' �s��;��`� c..:�� s-`a ,c�:� 'F .a�'y��,g�, �F{r ry•� y y � fi. va^'- � 'A F' �e . F.�.rS rF'"t+ !`A •,, �" r- _��t�'V2i gra r bot..ter•gra". ' ,1-4 .L`5 ww,tU ,�•4'i�. f' Y.-est v Y »,a •o-�,,�,,,r..:.'U t vTt� 'f* ' T �r1 _✓" -i` ge 5 L -i h �- t i � '� � + i, i�xt V c ,••x,�,.�sV�I-��y��.^c,{.c �. �",�Zl'.b�t,,�� .t�r�`�',�,�y...r-,•. i-t +, t"�i'+" �� 1'..3 �" ;t�v?r. + ::3 '}� .0.r. 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'�.'''fir a''' try t -k5-.,_�'"�',.r 5u '}� -yx r-�� "S• St � u +�'Y cJ.*P..E4 '4••a aw'cr7'.r 3- '`��. a�5�cs�`cr } i f '^''� � t�•�-rr'��,4 Y ri� Wku- °¢5 �d. ..1`.n,y.�1Ni.._.c._:eL'...»R.L+�r-..tA��r:�`� •F-_yf+,.P'' 1_ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more.family Industrial Alteration No. of units: Commercial air, replacement- Assessory Bldg Others: Demolition Other ty y 5,p rT� ��I�^��s1+.E.^h L �F �' � G' ��iJ�.W �� sG �`��y� .�."��A/�y7 v-��y^�M•�t` �' •py� �.`�,� 2- i �vw. 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YA._ ..!S_n.s__, ..._.;.a.= ,.�+•.-&n-�nr.�r.�•r•;J � .-� '�� 6 - Jli. � DESCRIPTION OF WORK TO BE PREFORMED: el l� Identification PIease Type or Print Clearly) OWNER: Name: L Phone: 7dL'� A /(44� Address: a � =a, � t "' F' Y,.,y +.,.� ` �i{s�, i t.s•��"•': �L�' 7'c.c St:.9u*"x"4„ , r`-il,1J.a..-•�.r�r.. „4 �.s..-mac��t�, �drt�.�¢$. �:?-l,sax'�""�"�-��..'[.-� kaa,�i w.'�1 + t� "�`y •c�.' s-` 'ai�?5'_-'"'.`='7.".�,dK.a3c a7'�,+-_�Lx,"•:`u!r'--::� e.�,d6' w1c 'YJ( �r+" -tz;•. .ti��.X 'r-IS' y��.rL.,'3�''1. .ii -l`ar�r" -�3-a�-�"c.rt+- 4�.,`."''' "'�, 'ti, +". ••�`„-2{' i -r'¢`�,'�.rxr��_t- ai7':4'4F Nti'<MGµ-� SA m .�.a� a*�c�.�- -= .. a].'c- Sc{.- t �..1','°r`'¢�8 r�r ��dit . 'Yt'"_•.-c'.+FS'�uFT.i�rs. "^'3•' ��-}i^iY.,i7 lye g"Y - -• SFr ;ry i e7. C r s`L,'"' .s 3 ,f''w,i>",�.y7r i , - 7 'Lrs-,si m:,-' ' «,.- _r •�,�z" r�` Ar��-• i �R's�".4tt�!^�^' ' ��-,, y"Y5' t° .y -cam.' �_a*.��yl^r_ , 'a �.< �r`'ry-,yc°'` -' a ti 1�r C x� J�*cr riesr µesti .f* "a 'tt. si.s-a.,r:§'rr�-.Yo-�». a�r.i•;,,, �-u_ u ,F vFt ;. "f"' gib. sLtl - `"' .a7•' }a�'-,�tCYe i�'s��.-?�_r'��„�'Fa,lY;��lt�p r_.�'`�+h.p+kr+7s�.:rx�.i;+.S�-°,N�Tmo'�'1�iYi,P.l~"�"ai ia".•+ �';.''��n�.•cs��3.,�,YiJG�i _;:7�'i rz^4��1a,Ji r�q•'h��",�a. ��'�rfC"t,�Y�zr,.!�'fi�tY2�r7,Ykj'i,ri`s�e��r tC�.�e3hyn.1�r.r�,x.itJk�"iLr��;.,S�.. W 114131 . 1�p�� mT'�E"�>�;y"r°],��l'3�r`-t�f��3't��L.v,F,A.ct,rySw,yt�:✓''L•u}hF+'�`i-,R,,�.F'�{t�.i.r.x�..l}L.1.. r Ia`�,'��v�'R� .�r�:�-.s,. =••z..{;i' ..,,'� �,�•y.r � wr,.j�.,�4,?4h;*_�h--:>�Y�,+:�gk'�'aT i'7 :�r^ �-`x..Il'�,f�"�w�+�' 2,�.tip.+�.:•,';�_�a°r-�•,. F`�'j'Y��ir-.s,M:-. � _ _ `h sd'.-,�_ �i.�i �--'^ vlY3;,.Ip�t�,k39✓, �i ,.�'�i+(p•.Y�1 �2.taY yWf r-iI^T�4"S,_c !f..'_^cxty�'1-l._"''�r�,,llrkf G yN ,,.r]"..4.. zF r�'(h%*-,�q"•4 y��' aj'P ry� .�T�''; ,�.�,?� �3,:.Y��,.�.�s-`eYa'•:ui;ic M+e�r�`zr'`Jf>�jc`T�' a p�m ,artu•� #r�'+�x`7 T �u.�sl�r r,4-,•-N�i��F S'r,*�S,ji�A4,�_7'i� �x �.�4t'�Ertr �kS•-'a fi-a, f� r� —.r-- ,su..:..la.. `.3 k'.,E--"r yr�:Y„�- k- Tr t �t'r"-' q' �i�i� 4� t_ yr n � '•.-Ce �� -_ '�';3�e;,.��-r...".!:ir�j• y'3�7,7 �� .�' r 'z'%';,�..!.'• t ''�L"� � �. ht .,. .rt2"'�� '_' �:z:� � � („r. -x".N C �.,,, �S,T��/ �'f��t, ��-•..�i�.�-.�c:�z2�.'4_-"^ `'�, :'4�. '�'�`.?�'�'r�^:1`..',z' rf'"3"r,e�-. �y�" r t.-,- n1�:� .�:},�`.�' �.`'7-�V� :�-i �•s"� y+ �., _ _.uu.. � .:F�7r r.^�-=� 1'kn.�Jr.�» �+T t�+�''O7�"moi-,7 ;gr��• �,� ,t#f"-•�'-m�•+. a4,� ARCH ITECT/ENGINEER_ Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$123.00 PER S.F. Total Project Cost: $ ��D. T�� FEE: $ Check No.: U 1 Receipt No.: NOTE: Persons contract g with unregistered contractors do not have access to t e, aranty fund S�i n��ire��f�A �nt/O �arvnary eT _ � _ - �.;:�� Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature C C11AVIEIV T S HEALTH Reviewed on Signature COMMENTS 4 + Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water $ Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street : ;R `�ETlfl leap'Dia tte ono :fWbAtad 't12lain treE# x ; r y' parM-M0n1S-' 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 - Date Doc.Building Permit Revised 2010 Building Department The following is'a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or..Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ IVI " "ass check.Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit '--...New Construction (Single and Two Family) ❑ Building Permit Application ❑ Ceiiif led Proposed Plot Pian ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2008 Location No. Date �aR,h TOWN OF NORTH ANDOVER 3� • • O AL16. ' 9 .Also Certificate of Occupancy $ ^C CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # lU 24996 wilding Inspector J� -Commowweald Office of Consumer Affairs and usiness Regulation 10 Park Plaza -Suite 5170 Boston, Massachusetts 02116 _ ! Home Improvement actor Registration Registration: 135292 Type: Individual jExpiration: 3/22/2012 Tr# 292451 JONES BOYS INSULATION ry DON BURNETT PO BOX 266 r. DANVERS, MA 01923 r � Update Address and return card.Mark reason for change. E] Address Renewal E] Employment F Lost Card DPS-CAI 0 50M-04/04-GIO1216p S'l-\ �iie TJO�It7ilYtoOzcueltGl/ O�i/I�CQbdl�Cl7A,l6P.�6 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration; ,'l 35292 10 Park Plaza-Suite 5170 Expiration 3/22/2012 Tr# 292451 Boston,MA 02116 S Types jr It+ +viduat. 'u ` , JONES BOYS INS Ut7fOl^ = DON BURNETT r` 4 CHARTER STREET xa l' -- DANVERS,MA 01923'" ":`- Undersecretary Not valid without signature s AC 0® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/28/2011 4 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. N 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 NAME. T Oi Aon Risk Services central, inc. Southfield MI office (PHONNo. E)rt: (866) 283-7122 NIC No.): (847) 953-5390 0 3000 Town Center EMAIL :2 suite 3000 ADDRESS: 0 Southfield MI 48075 USA x INSURERS)AFFORDING COVERAGE NAIC Y INSURED INSURER A: Old Republic Ins Co 24147 Builder Services Group, Inc. INSURER B: ACE American Insurance Company 22667 d/b/a ]ones Boys Insulation AMasco Corporation Company INSURERC: indemnity Insurance Co of North America 43575 P.O. Box 266 4 Charter Street INSURER D: Danvers MA 01923 USA - - INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:570042658546 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. Limits shown are as requested LTR TYPE OF INSURANCE INSR WVD POLICYNUMBER IMMIDDIYYYYI MMID LIMITS A GENERAL LIABILITY MWZY EACH OCCURRENCE S2,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occunence S2,000,000 CLAIMS-MADE X❑OCCUR MED EXP(Anyone.person) i $25,000 PERSONAL&ADV INJURY 52,000,000 GENERAL AGGREGATE $5,000,000 OD GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $10,090,000C X POLICY PRO- LOC IJFCT p A AUTOMOBILEUABIUTY MWrB 18398-11 06/30/201106/30/2012 COMBINED SINGLE LIMIT E5,000,000 (Ea aan X ANY AUTO BODILY INJURY(Per person) O ALL OWNEDSCHEDULED BODILY INJURY(Per accident) Z AUTOS AUTOS .m., NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident 1: 0) UMBRELLA UABOCCUR EACH OCCURRENCE V EXCESS UAB CLAIMS-MADE AGGREGATE DED RETENTION C WORKERS COMPENSATION AND WLRC46480648 06/30/201106/30/2012 X I WC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITSR ANY PROPRIETOR/PARTNER I EXECUTIVE YIN Deductible - AOS B OFFICERIMEMBEREXCLUDED? N N/A SCFC4648065A 06/30/201106/30/2012 E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) Retro-- AZ,HI,MA,OR,WI E.L.DISEASE-EA EMPLOYEE 51,000,000 K describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S1,000,005 B Excess INC IWCUC46480624 06/30/201106/30/2012 Retention $2,000,000 Self-Insured States Statutory Included SIR applies per policy terns & conditions DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,U more space Is required) at 2 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE tXfO�b t`��'rQrfG f�/�iGUE1Cl7 <r��d7tGZQ%>L J77GL 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations' 600 Washington Street 5� Boston,MA 0211.1 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers My licant Information . please Print Le ibl Name(Business/Organization&dividual). p �, Address: .City/State/Zip: �il/v��/' �l - one 2737 Ar ean employer?Check the appropriate bo . a employer with 4. I am a general contractor and IType of project(required): loyees(full and/or part-time).* have hired the sub-contractors 6• ❑Ne construction a sole proprietor or partner- listed on the attached sheet.t 7• - emodeling and have no employees These sub-contractors,have 8. ❑Demolition ing for me in any capacity. workers'comp,insurance.workers'comp,insurance 5. ❑ We are a corporation and its 9• ❑Building addition ired.] officers have exercised their 10•❑Electrical repairs or additions a homeowner doing all work right of exemption per 1VIGL .❑plumbingrepairs or dditions lf.[No workers'comp. c.152,§1(4),and we have no ance re aired. T 12.❑Roofrepairs q ] employees.[No workers comp,insurance required] I3.j]Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that isproviding workers,compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:_ A Policy#or Self-ins.Lic.#:_ Expiration Date: O Job Site Address. , City/State&ip:—A 202y�Z Attach a copy of the workers'com enation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. P P .fP J rY ` I do hereby certify under the airs and en o er'u that the information providedabove is true and correct:_ Signature: Date: Shone#: Official use on- Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbingInspector 6.Other Contact Person: ' Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their 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 enterprise,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 ofpublic 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 Liatility 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 Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for 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. PIease 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(ifnecessary)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 notrelated to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOTrequired to complete this affiddvit. The Office of Investigations would like to thank you is advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The GO.-MMO nweal`ua of Afjassaclausetis Department of T dushial Accidents OMCC of InvestlgatiouS 600 Washington Straet Boston,.11-A,02111 Tal.#617-727-4900 ext 406 ox 1-877-MAss,AFE Revised 5 26-05 Fax#617"727-7749 '4 w.]Zias.s.g-4vjd10. IAORTH To'11111111� 0 f Andover 0 No. 5SI oy dover, Mass., (A COCHICHEWICK PS` 0RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT................. ..............6-e_A�............................................................................... BUILDING INSPECTOR .......................... Foundation has permission to erect........................................ buildings on ...... ....... . ..... ... ............................................... Rough to be Occupied as................. .......... ................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final 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 E)TIRES IN 6 MONTHS ELECTRICAL INSPECTOR 3 V UNLESS CONSTRUG44QN AR 1 S Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Der. ' Glumt& Gas® :. of Massachusettsi �, f /� ./' A NiSource Company �( yy Gas Account# Audit Request# PRELIMINARY AGREEMENT =. READ THIS AGREEMENT AND MAKE SURE YOU UNDERSTAND IT BEFORE SIGNING. MAKE SURE ALL BLANKS ARE. COMPLETED AND ALL PROVISIONS THAT DO NOT APPLY ARE CROSSED OUT. THIS AGREEMENT HAS LEGAL MRCS AND EFFECT AND'BINDS THOSE WHO SIGN. This Agreement is made on 1 /f between Honeywell of 65 Shawmut Rd, Suite 4, 2"d floor, Clinton, Massachusetts 02021,(800-247-4112)hereafter called"Administrative Contractor"or"Honeywell"and , Lof (�FC/)u/sto fr//�/�Jn i' { J/�J Y+/. ( cX, \ (Address) � / / /yy !V oa !/ -4 p �� r"• t 01,P tJ \ ry V J r Lam,G' a (Address cont.) (Telephone) Hereinafter called"Customer."The Customer is the e Tenant of the above-mentioned PreWises. DESCRIPTION OF WORK TO BE PERFORMED In considerationof the Administrative Contractor's agreement to select a qualified Installation Contractor to perform it workmanlike manner all work("the Work")set forth in the attached Work Order(s),the Customer agrees`to¢ihe termi conditions of this Agreement. No Work maybe performed without the written consent of Owner. Cusiomer understal calculated energy savings are estimates only and are not guaranteed. PRICE For Field technician use only: COMMENTS: O For the Work described in the Work Order(s)and shoNyneon p SEE HEALTH AND SAFETY F the accepted Offer Sheet,attached hereto, r ❑ OTHER Total Estimated Cost is$ l JO S (� Ca� �vat a - m The Total Due at the time of Installation from $ rW the Customer for the Work to be performed is: C. `��' `4 Z If the Installation Contractor determines,thaphe Work cannot be provided for the Prier quoted above,I m W will have the,right to terminate this.Agreement. Price quoted is valid for 90 days. w o Zgo do Owner of the Premises agrees to; pay;prior,to the commencement.of the Work,and Administrative Contra( in full satisfaction for the Work the Price set forth above: ~O W • Tenant agrees to pay, prior:to the commencement:of:the Work, and Administrative Contractor accf < satisfaction for the Work the Price set forth above. RIGHT TO'CANCEL THE CUSTOMER MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED AT A PLACE OTHER THAN A..I�N AD JDA+ THE ADMINISTRATIVE CONTRACTOR, WHICH MAY BE ITS MAIN OFFICE OR BRANCH THEREOF PROVIDED THAT THE &Wmkk NOTIFIES THE ADMINISTRATIVE CONTRACTOR IN WRITING AT ITS MAIN OFFICE OR BRANCH BY ORDINARY MAIL P6STt+, BY TELEGRAM SENT OR BY DELIVERY,NO LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT.SEE NOTICE OF CANCELLATION(IN DUPLICATE)ANNEXED FOR AN EXPLANATION OF THIS RIGHT. IMPORTANT:ADDITIONAL TERMS AND CONDITIONS ARE ON THE REVERSE SIDE By signing below you,the Customer,represents that(1)You read and understood both sides of this Agreement before you signed it;(2)You agree to be ound by the terms and conditions set forth on the front and back of this Agreement;(3)The Administrative C for(directly or indirectly)has made no representations or warranties regarding the Work other than those contained in rs A �e�ment;(4) t at the time you signed the Agreement,it has been signed by the Administrative Contractor or its ad 'n�ati f�epresentatiye there were no blanks that had not been completed and that the Work you requested was propel} descri !above. /� �C/ Honeywell ignature r Date Owner's Signature Date Tenant's Signature Date MAIL THE SIGNED`A_GREEMENT TO: HONEYWELL 65 SHAWMUT RD,SUITE 4,2 ND FLOOR- CANTON;MA`02021: Honeywell-White - --Installation Contractor-Yellow Customer-Pink Revised10/2010 Uzi ' REORDER:ZIPRINr 781.963-2250