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Home My WebLink AboutBuilding Permit #283 - 19 MEADOWOOD ROAD 10/6/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ?3 Date Received Date Issued: ! -(J IMPORTANT: Applicant must complete all items on this page LOCATION YCD L O'n P ntPROPERTY OWNER V I U(.s.1' . Print MAP NO PARCEL: ZONING DISTRICT: Historic District yes no Machine.Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family LI-11" Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) Vn n OWNER: Name: 'rtiJ�� Phone: Address: CONTRACTOR Name: s -kWIZ' '0 Phone: -06 c� Address: U CU to C cr Supervisor's Construction License: Exp. Date Home Improvement License: Exp. Date Id Al 4 ARCHITECT/ENGINEER Phone: Address: Reg. No. 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: $ � � UO Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund signature of Agent/Owner Cir �_7 Signature of contractor` ' Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site I [ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS a� 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 FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 MainStreet Fire Department signature/date COMMENTS 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 2008 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) ❑ Mass 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 ❑ 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 ❑ 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: Doc.Building Permit Revised 2008 Location/fA-��-. -..►. No. � ' Date NORTH TOWN OF NORTH ANDOVER i Certificate of Occupancy $ , c"us`� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 07 Check # 22508 �1-- Building inspeMbr NORTH ® of gov r 0 e doves Mass, /0 • &D 4 COCHICHEWICK � D PQ S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.......... .. ... . BUILDING INSPECTOR Foundation has permission to erect........................................ buildings on j fir. . Rough .. ............ .................... ..... ....... ... • to be occupied as.......��... .. . ......... ....................................................................... Chimney provided that the person acce ng this p��hillevery respect conform t..the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIONS TS ELECTRICAL INSPECTOR ........................................... .... . 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. 49601 (expies Rcnew,al F NEWAL EY ANDERSEP MA License Felderal Tax ID#r83-04042101) byAndelsen. - WINDOW REPLACEMENT OF GREATER A/LASSACHUSETTS AND NEw HAMPSHIRE 104 Otis Street•Northborough,NIA 01532 t Phone 508.919.0900•Fax 508.919.0903 CUSTOM WINDOW AND DOOR REMODELING AGREEMENT Buyer(s)Name - Date of Agreement C,4/R a G Buyer(s)Street Address,City,State,and Zip Code D ow 0-010 �'t-� ovv& ,1,03ve/L/ E-Mail Address - Home Telephone Number Work Telephone Number Buyer(s)hereby jointly and severally agrees to purchase the products and/or services of J&L Windows,Inc.dba Renewal by Andersen of Greater Massachusetts and New Hampshire("Contractor"),in accordance with the terms and conditions described on the front and the reverse of this agreement and on the attached specification sheets)(collectively,this"Agreement").Buyer(s)hereby agrees to sign a completion certificate after Contractor has completed all work under this Agreemen Method of Pymnt:O Cash Q Check O Mastercard ❑VISA /Total Job Amount. Estimated Starting Date: p Discover Financed,App / NDeposit Received(33%, Name on Credit Card: glance at Start of Job(33%y p Credit Card#: yt Estimated Completion Date: Balanc on Su[ to tial �'O/ CO/< Compl ion of Job(33 CC Exp.Date: CC Security Code: B•initialing here,you acknowledge that the Balance at Start of Job and the Balance on Substantial Completion Buyer I 'tials of Job cannot be made by credit card and must be made by personal check,bank check,or cash. Buyer(s) ag es understands that this Agreement constitutes the entire understanding between the parties,and that there are no verbal understandings changing or modifying any of the terms of this Agreement.No alteration to or deviation from this Agreement will be valid without the signed,written consent of both Buyer(s) and Contractor.Buyer(s) hereby, acknowledges that Buyer(s) 1) has read this Agreement, understands the terms of this Agreement, and has received a completed,signed,and dated c of s grcement,including the two attached Notices of Cancellation,on the date first writVoPr oralli' or of Buyer's right to cancel this Agreement.DO NOT SIGN THIS CONTRACT IF THPA Renre NH Buyer(s) Buyer(s) By: i I. -,t, lan er Signature Signature �� l u)k Print Name of Product Manager Print Name Print Name , YOU, THE BUYER(S), MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORMS FOR AN EXPLANATION OF THIS RIGHT. �c — — — — — — — — — — — — —�<- - — — — — — — — — — — — -�— — — — — — — — — — — — — — — � NOTICE OF CANCELLATION X NOTICE OFC NCEL TION Date of Transaction . You may cancel Date of Transaction <9 e"?M 2.You may cancel this transaction,without any penalty or obligation,within this transaction,without any penalty or obligation,within three business days from the above date.If you cancel,any three business days from the above date.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract of Sale,and any negotiable instrument executed Contract of Sale,and any negotiable instrument executed by you will be returned within 10 days following receipt I by you will be returned within 10 days following receipt by the Seller of your cancellation notice,and any security I by the Seller of your cancellation notice,and any security interest arising out of the transaction will be canceled. I interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at If you cancel, you must make available to the Seller at your residence, in substantially as good condition asI your residence, in substantially as good condition as when received, any goods delivered to you under this I when received,-any goods delivered to you under this . Contract or Sale;or you may,if you wish,comply with the I Contract or Sale;or you may,if you wish;comply with the instructions of the Seller regarding the return shipment of Xinstructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk.If you do make the goods at the Sellers expense and risk.If you do make the goods available to the Seller and the Seller does not the goods available to the Seller and the Seller does not pick them up within 20 days of the date of your Notice I pick them up within 20 days of the date of our Notice of Cancellation,you may retain or dispose of the goods I of Cancellation,you may retain or dispose of the goods without any further obligation. If you fail to make the I without any further obligation. If you fail to make the goods available to the Seller,or if you agree to return the goods available to the Seller,or if you agree to return the goods to the Seller and fail to do so,thenyou remain liable Igoods to the Seller and fail to do so,then you remain liable for performance of all obligations under the Contract. for performance of all obligations under the Contract. To cancel this transaction, mail or deliver a signed and I To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written I dated copy of this cancellation notice or any other written notice, or send a telegram to Renewal by Andersen I notice, or send a telegram to Renewal by Andersen of Greater Massachusetts and New Hampshire,6 104 I of Greater Massachus tts nd New-Hampshire, 104 s Otis Street,Northborough,NIA 01532, NOT LATER THAN I Otis Street,Northb o h, 01532, NOT LATER THAN MIDNIGHT OF .(Date) MIDNIGHT OF 6 .(Date) I.HEREBY CANCEL THIS TRANSACTION. X I HEREBY CANCEL T IS TRANSACTION. I Consumer's Signature Date I Consumer's Signature Date RbA Copy- White Customer Copy-Yellow Customer Copy-Pink Renewal %% RENEWAL BY ANDERSEN MA License#149601(expires 1/24/10) bY�4ndersen. �� /+UCATT MASSACHUSETTS �,{,cC l� T i i�r�C Amain 7�T HAMPSHIRE J��. C ULA Federal Tax ID# 83-0404201 WINDDW REPLACEMENT =Md—C—pe y OF lI1WA1 LR iV1t1JJAl.H VSLI IJ A1VL NEW 11t11V1PJH11W 104 Otis Street•Northborough,Massachusetts 01532 Phone 508.919.0900•Fax 508.919.0903 A SPECIFICATION SHEET { Buyer(s)Name Date of Agree nt The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on the Specification Sheet and the front and the reverse of the accompanying CUSTOM WINDOW AND DOOR REMODELING AGREEMENT,of which this Specification Sheet is a part. WINDOW DETAILS 1. Cogtractor will Install a total of windows in Owner's home,using the following individual quantities: Ej Double Hung(DB)�9 Equal sash ❑ Cottage sash(1/3 top,2/3 bottom) ❑ Oriel sash(2/3 top.1/3 bottom) Casement(CW) ❑ Hinge right ❑ Hinge left(as viewed from exterior): ❑ Standard handle ❑ Metro handle Double Casement(CDW) ❑ Standard handle ❑ Metro handle Casement/Picture/Casement(CPW) ❑ 1:1:1 or ❑ 1:2:1 ❑ Standard handle ❑ Metro handle 2 Lite Gliding Window(GW) Glider/Picture/Glider(GFW) ❑ 1:1:1 or ❑ 1:2:1 Awning Window(AW) Picture Window(FW) Bay or Bow Window Patio Doors(see separate Door Specification Sheet) �� 2. E Yes [] No Qty of Windows to be Custom Fit Replacement: 3. ❑ Yes-M No Qty of Sills to be replaced by Contractor: 4. ❑ Yes No Qty of Windows to be New Construction Full frame(includes new interior&exterior casings) Exterior casings: ❑ Pine ❑ Maintenance-free material ❑ Factory applied 908 Fibrex brickmold 5. Glazing to be:tJHow�(&SmartSunTM (T AxCredltEGglble) ❑ Other If other,please specify:6. Exterior color to bite ❑ Sand ❑ Canvas ❑ Terratone ❑ Cocoa Bean7. Interior color to bWhite ❑ Sand ❑ Canvas ❑Terratone ❑ Pine ❑ Maple ❑ Oak Note- Interior color can only be white,wood or same color as exterior. Wood interiors need to finished by Owner. 8. Hardware, White ❑ Stone ❑ Canvas ❑ Brass Double Hung: 9. Yes N stall Lifts with Double Hung Windows /�S Tia�� /V 1)/�s d�! S %Q FC)A— I (T^ KJ 10. O" , s: windows to have: F-1 Half or ❑ Full screen Screens to be: ❑ Fiberglass ❑ Aluminum TruScene v� t /A G w S GRILLE DETAILS Q c y 11.Windows have grilles: ❑ Yes N f yes:❑ Grille Between Glass(Gsc)❑ Removable Interior Wood umw)❑ Full Divided Light(rot,) Qty: Qtr: Qty: Qty Qty: Qty: Qty: DH DH DH DH CW/PicWre Glider CPW r Draw grille patterns above *Use additional sheet if needed Owner approved ADDITIONAL WORK DETAILS y 12.❑ Yes 4 No Contractor will remove metal frames of windows. Qty of Units: 13.❑ Yes No Contractor will install new paint-ready or stain-ready casings. Interior casing qty of openings: Exterior casings qty of openings: ❑ Pine ❑ Maintenance-free material 14.❑ Ye, No Contractor will install new paint-ready or s ' -rea y outside stops qty of openings: Interior stops qty of openings: Exteri stops qty r' enings: ❑ Pine ❑ Maintenance-free material 15. Owner is aware that Contractor does not do any p O r Initials 16.❑ Yes-R No Contractor will wrap exterior casings wi In of color. Note: Wrapping may be required with storm window remova;removal of storm windows will leave screw holes in casing. i_7_R Yes'ff5,No Contractor will insulate,caulk and seal windows with 3-point system to prevent water and air infiltration. 18:[3 Yes ❑ No A limited warranty shall be issued to Owner upon completion of the job and payment in full. 19JR Yes ❑ No Building Permit—Contractor will secure any and all necessary permits. The fee for the permit(s)is not included in the Contract Price and a separate check is required at the time of sale for this fee. 20. dditiona;job details: !�VZ,4 r,,,vz 6/V e C D W ,/zf el 04 7''W o 4991-S w / 16-, l 4 J 21. ❑ Yes ❑ No Owner agrees to be present on the final day of installation for final inspection and to deliver final_payment. No final payment shall be demanded until the contract is completed to the satisfaction of all parties. It is agreed and understood by and between the parties that this Specification Sheet,along with the CUSTOM WINDOW AND DOOR REMODELING AGRE to a entire understanding between the parties,and there are no verbal understandings changing or_ modifying any of th S ation Sheet may not be changed or its terms modified or varied in any way unless such changes are in i and sign a (s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read this Specification Sheet. Re ewal n to d NH s )l Buyer(s) pj 1grlature f Product ager Signature Signature ado Print Name of Product Manager Print Name Print Name RbA Copy- White Customer Copy-Yellow The Cornmonwealth of Massachusetts - Department of Industrial Accidents QJJice of Investigatiolls ' 600 IVashington Street . , Boston,M 02111 n'ww.mass.,0v1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricia:as/Plumbers ADnlicant Information Please Print Legibly NaMe(Business/0rPaniza6on/Individual): 0i Address: City/State/Zip: ,�l�r-1�ba l'a , X14 J). J.�,_ Phone= Are'you an employer?Check the.approprate box: Type of project (required): L&I.am a employer with 09c) 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* ' have hired the sub-contractors T 2.❑ I am a sole proprietor or partner- listed on the attached sheet# ` .emodeling ship and have no employees These sub-contractors have S. Demolition worldng for me in any capacity. workers'comp.insurance., 9. ❑Building addition LNo workers'comp.insurance 5. ❑ dile are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c.162,§.1(4),and we have no 12.[]Roof repairs insurance required.]t employees.[No workers' 13.7 Other comp.insurance required.] :Any applicant that checks box r1 must also 0 out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work:and then hire outside contractors must submit a new affidavit indicating such. $Contractor that check this box must attached an additional sheet showing the name of the sub-contractors and their worke s'comp.policy information. lam an=,Ployer that is providing workers'corrpersadon insurance for my employees. Below is the policy and job site information. / J Insurance Company l\Tame:_ z]Cts t�rl l7 C J Policy#or Self-ins.—Tic.,E: Expiration Date: Z) Job Site Address:_ N\tAOGWo()] U�k-> City/State/lip: Af4ch a copy of the m,orkers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25.k of MGL c. 152 can lead to the imposition of criminal penalties of a. fine up'to$.1;500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP'WORK ORDER and a fine 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 DLA for insurance coverage verification. I do hereby eer tPY under the pains and penaldes,of perjury that the informationprovided above is true and correct / Signature DatA 1 / Phone 0 Official use only. Do not write in this area, to be completed by city or town official Cl)-or T oTvrt: Permit/License iss1.ting 4mt<`harit�;q Lrcle arse): , F ` 1.Bozrd of Health 2.Bmildins Department 3.Ci y/Toivn Clerk 4.Electrical Inspectors Plumbing Inspector 6.Other Contact Person: Phorre:�: Date..........I �.`� 1...................... O�NOnTh,1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88�CHUg� This certifies that ...................... �V` :�..................................................... illation JnAn . � :�:...has permission for as instt inthe buildings of........Le...�-r-�..........................................................:..:...................... ac rJ�,.��o�C , North Andover,Mass. at.....�.. .. .. ....................................................... . ... M ..............................FeeJ. t7"' 3r4 ......................... GAS INSPECTOR Check# -{l F 9530 Date'11.15. ......... 10739 "SRT" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING nn This certifies that.....,...... Cil►,c)t�S . :' has permission to perform .......� .�................................................................ plumbingin the buildings of..........:.................................................................................. j ! r" a , North Andover, Mass. at........................................................................................... Fee...�.......Lic. No. �3�rl�? �"A. ........... ............................................................... PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ✓ I MA DATE jjPERMIT#j 0� 1 1 V V7 , 7 JOBSITE ADDRESS J1 OWNER'S NAME POWNER ADDRESS TEL � �— a2 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY( NEW: D RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES® NO FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Q BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _ 1 _ _ 1 __. 1 —1 1 3 DEDICATED GREASE SYSTEM J _...__.J 1 _. I i DEDICATED GRAY WATER SYSTEM 1 . ._ I I _ 1 I _._ ( i � ( __- f 1 k^ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) - _.1 K!•TCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK _ 1 _( ( # _ I _.1 TOILET 1 _.._....( � . _._ A—._( _.—_J .-___.� __.,._i ------ 1 URINAL ! ..._...- x WASHING MACHINE CONNECTION WATER HEATER ALL TYPES o _1 l i WATER PIPING 1 _` OTHER � ,1 1 1 1 i ! I i f= � -- ----------- J _._._._1 .-----._-I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R'NO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L3""� OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER a AGENT (0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and a rate to thelast of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c lian i all Pe ' e rovision of the 1k4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ V FS _ -- -�LICENSE# SIGNATURE MPR( JP 0 �— CORPORATION _J#PARTNERSHIP Q#=LLC i COMPANY NAMES�aqU �_ !P+ ADDRESS CITY _ WL _..__...._.- —I STATE j� xtl ZIP Q J � —E TEL y U iVim .. ._ FAX ; CELL EMAIL _� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPEC-TION NOTES Yes No / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Y FEE: $ PERMIT# PLAN REVIEW NOTES A ------------ r. e# 7 ' e t i �- The Commonwealth o,f.Massachus'etts , Department of Industirial AccMiks Office oflnvestigations 600 Washington Street Boston,MA 02111 www.mass gov/dza Workers'Compensation]insurance davit:Builders/Cont°actors/ElectriclanslPh mbers ApILhean Information Please Prim Le ibly' Name,(3usines/0rgani'zation/tndividual): � . �a�j t/y_J or � r� ,'SNC• Address: 2(2oiz h cS'f• V.)J� l l• - City/State/ZipPhone#: Are yo4.an employer?Check the appropriate box: Type of project(required): / 4am general contractor and I ` 1. am.a employer with CD . ❑ X a g 6, ❑New construction , employees(fall and/or part-time).* have hired the sub-contractors 2111 1 am a sole proprietor or partner listed on the attached sheet.t 7, ❑Remodeling ship and`have na employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance, g• ❑Building addition LNo workers' comp.insurance 5, ❑ We are a corporation and its 10.[!Electrical repairs or additions required.] officers have exercised.their 11. bin repairs or additions right of exemption per MGL g. p 3111 am a homeowner doing all work g p p myself V0 workers'comp. c.152,§1(4),and we have no UP Roofrepaixs insuraucere icedemployees.[No workers' � .] comp.insurance required.] 1311 Other Mny applicautthat ckecks box#1 must also fill out the section be16w showingtheir workers'compensationpolicy information. t'Homeowners who submit this affidavit iadicatingthey ore doing allworlc and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheokthis box must attached as additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees .Below is the policy iwd jab site information. Insurance Company Name:. /C -rCNQX //7 Policy#or Self-itis.Lie.MA) /l� / 7. Expiration Date: 2� Job Site Address,, 19 /!��ad� / • City%State/Zip:/U A24e/ '` K, Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage,as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a tine up to$1,50 0.00 and/or one-year imprisonment,as well as civil penalties iti the form of a STOP WORD ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office-of- Investigations fInvestigations of the DIA for insurance coverage verification. Ido liereby cert under tl ep • penalties ofperjury thatthe inforrnatlonprovidedabov, is true and correct signature: Date: Phone#• 9 _ 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#: h: Information and Instructions . Massachusetts General Laws chapter 152 requires all employers to provide worker's'compensation for their employees. Pursuanit to this statute,an erizployee is defined as"...every person in the service of another under any contract ofhire,- express orimplied,oral or written." An employed 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 tnistee 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 Tt dwelling house of another who employs p'er`sons to do'anaintenanca,,cor sttuction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because fof 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 iii:the commonwealth£or 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),addresses)and phone numbers)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 LL C or LLP does have employees,apolicy is required. Be advised thatthis 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 retumed 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 andprinted 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 fll'iu thepermit/license number which will be used as a reference number. In addition,an applicant that must submitmultiple permit/license applications in any given year,need only,submit one aftidavit`indicating current policy information(if necessary)acid under"Sob Site Address"the applicant should write"all locations in (city or towh.)."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 b e,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 orpermit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have anyquestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: �. The CQ QnwealtjLorVossarhv&etls - DOPUtX7 oUt QfWu*iaal,Accidaula Off oe of JAVOStIg4ona 6bG Washiagtm St=-.t Boston}MA 02111 TO. 617-7-2'x-4•.-QQ est 06 Qx 1-877•:MASSAM _ Revised 5-26-05 `ay,0 617-727-7749 WwW4as,q,g4vfcia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# O JOBSITE ADDRESS /c/- /7Pd�d1�. ��- OWNER'S NAME – ,� — G OWNER ADDRESS rt.TE •- (} FAX TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:F—qr'RENOVATION:El REPLACEMENT:® PLANS SUBMITTED: YES 0 NO a' APPLIANCES"I FLOORS- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BOILER > D — _L. BOOSTER CONVERSION BURNER COOK STOVE E—J - - DIRECT VENT HEATER J DRYER T. FIREPLACE FRYOLATOR FURNACE Q GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER [�— OTH_ER ,_ F INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES CR NO [j I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER -jf AGENT E] SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pert' ovi ' he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER- SFITTER NAME _ PS• _—_--=LICENSE# SI NATURE MP MGF EI JP [] JGFR J LPGIE1 CORPORATION Ej# / �J PARTNERSHIP[J# LLC(]#= COMPANY NAME: ]�Y�i� v _ +�kk, __ ADDRESS CITY _ _ � STATE� ZIPTEL � FAX ELL *MAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION.4NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT PLAN REVIEW NOTES . fi P c¢ f F ° Ar, rt COMMONWEALTH OF MASSACHUSETTS BOARD t1F PLUMBEF;S AN'D GASF ITTERS: ISSUES THE FOLLOWING LICE E :» L1`CE1dSfp AS A MASTER F'LUMB ALUAM IF 0 GUNDES 82 F A I RkAWN'-ST LO FELL MA 01851-46:1:6 131; 5 05/0)t, 1:6.: ::: 199335 f � dOMMONWEA .H OF MASSACHUSETTS: BOARD>O� PLUMBERS phJ'b GASFITT ERS: [ ISSUES THE FOLLOWING .,LICE E t¢ REGISTER> D ASA PLUMB I NG 1� w ALVARO FAGUNDES y A�77 F'11GUND:ES 1?LUMB I NG & HE 82 FAiRLAWNST MA 01851 3 (ORE 199331 358'..1 05/°1. 16 i + f i' ••`� fie�a9a��rar .,¢�`��f � ,` � � Board of Euildin;Feg�aIatona and$taidards . - --__ - -- 'Ccr�sti►ction•SupErvEscrLlceraa••: ,4. �• . License CS 95707 3icthaa_�_��/i982 _ rypl"aI[D[I 9i8IZa10 Tr,- 2001 . Res�rlctiori_�O)i, BRIAN DENNISON _x'r`' t - 85 CREST CIRCLE �^-, � _ 1 WORCESTEr, A Oio03 J f Coinmissione - 1 RENEWAL BY ANDERSON . SP�IAN .DEC�NISON 10^ OT:IS STREET .f\!ORTHE0R0UGH, MA0.1532 . • DPS-CA1 ea 50NrL7f0i-?C84P0 �\ Board of Buildiul,gemulations and Standards 4,C)ME IN!pRO�EI�tEf TT CONTRACTOR " • '=' •� Ragistcafio�:; i49o`01 • 24/2010 -�_ p!amant Card RENEWAL BY AKD. ,! BRIAN DENNIS0t.-q ; 1D4 OTIS STREET'S== , � � `NORTHBOROUGH,MAI5i532 Administrator F � ?r9,a '*y. r.: dA!�uC/i/�?°° 4 SUR .d '.� OS/07 °'OOUCc� THS — � —/2009 I II E i..='�It CA re 9 b A� A WIA 2' OC INFORMA,TIO dK'i `.1rlm ONLY A rsP,` ,aea.e.am. ,db �6��L � Ffi R�� fa �S �3® F,S6�'.iT.� . 1vJC'cO1?r 11iaUfrl!C; n i J ,= i1 C�� L'yd �0r AWil—P'C E.a"�H�a OR , A:: ROED BY T = PO lCM'-!' s-LOw, RE: Ann A"tor, Ml 45105- 333 7=0 . INSURERS AFCoNG v-spr.,c� C ite;; a I P9�,aC RaBmswai y finde.son I INSURER A: Har—for;Ir;sL!t•=_nca Corlca°��' dc? indcws, Inc. a INSURER E: !-isr, di ace e F I r.��4E J`L INSURER C: NOrI`dGrough,WIA 01532 I INSURER D: CsJIJ INSURER e sRAGEv THE POLICIES OF INSURANCE LISTED BELOW FM--dEHld!SSUED TO THE INSURED NAMED ABOVE FOR T'H'E POLICY PERIOD INDICATcD..NO i IAlli HSTAWDIWG ANY PE+DUMEMENT,TERM OR CONOrl N OF my E--"—�T-RA OR =SUED OR ! OTHER DOCUMENT WITH RESP=CT TO WHICH THIS CERTIFICATE MAY MAY FERTAIN,THE IWSUPAN CE AFFORDED BY 7 HE P0LIC I=S 0ESCRI°E0HEREIN !S SUEJECT TO ALL THE TEFMS,EXCLLISiONS AWD CGWDITSOF SUCH POLICIES.AGGPEGAi:LIMrFS SHOWN MAY L�.VE 3E=�REDUCED 3Y FAID CLAIIVZ. N a�� T,LIUITAPPLI POLICYNUMe E4LWI ^;--P 507 404 09107,/29'09 OS1J712e10 �EACHC=UPRE:sC>:GENcPALUAPJLf t DJ?_lieu❑ R_i51!5e5rE_c'__ac. l I S �Co.Dori- MAO= OCCUR MED EXP(Any ane nersnnPEP.SONALZADVINJURYGENIERALAGGREGAic S 2.000.DDO E LIUITAPP(L!�=S PER:. PROOUOTS•CCMF`/0P AGG Is 2.000.000 I i PO'ICY J CT I I!C1^ A1T3MOSI Lt1a9(L . 2� MCC' va• J{ J n" (? '� 3'5 +riCC.;1u 5390 10/01,-00 °0101109 ComsINED SINGLE LIMIT 4 ANY AUTO ? 5 (esa eenq I s 1,0401000 ALL OWNED AUTOS Fr^DILYIkJURY SCHEDULED AUTOS (PgPery:n) $ HIRED•AUMMS NCH I3ODILYINJURY -0Wf1EDAL'TCS (Per a=dent) S PROPERTY DAMAGE I$ I� per a�denq WAGE LLA ILrL- AUTO ONLY.EA ACCIOSNT I$ IH ANY ALTO EA ACC S I OTHER THAN AUTO ONLY: AGO I$ --'`' En°"1J"A L SIL Y L EACH OCCUP.P_NCE I S CC:JR Q C',AIMS ltAOS - AvvR¢•'Aic 1 I S I$ MUC T IELS I Is WORI:EP.5=14PENSATION AND t g =.— q A A q o o WC STATu• ( 10TH•I EJP�Y'_@TLLL'!i� —_1 I�l� I—o4 O�`2 1(/GOO 0,211%'0 I v I I T^ :q ANYPRO PR'I,OFtL?AF,'TN1J7ME I=L EACYACCCE.NT $ 500.000 .. OFF!C:PlbIE•MSEA"CLUC D9. F' 'YEE S j00 5700 if yae,des,- a wider I E L O!SEASE•EA EMPLOYEE I 5F_CIAL PP.OV!SION=be'- I-L DIS=AS,-•POLICY!IMIT I S 5,00.000 OTY� 0=e"PIPTION OF'OPERA:iON:I LCCA 10k.I VE ICL_S! 'aICY.S AZOED EYFIGO°:E tO�i J SPECIAL, PROVISIONS" rm'TiFICA'=HOLDER CA FJ LA rzFJCSLT17.4 I+ ...0'ULZ AW Or e XF ABOVE DEz='zz9 90 '-^iES ME=,'._L=3C?JF:E THE EXP'=71CN jppp I I.: �D 1C0 pV _ 'rFa:-SULNG WSUF A'Al ' ENDEWOR TO P• a J 10 e-=,Z I (w+�s-.Y�iRv_ra.-.�iF:e+wT�Hve� e_ ode La.-7 ��.e n I S 905E te0 OaL'F`Ok On LSFclL"° Ce'.F P^ u"dO L'POk i�E IEtSU @EP,ITS &0C T_OR P it Fe�Pre.`-.-.ENT lv=_S. t } to�i•a u62-�, � _ i }