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Building Permit #437 - 193 ANDOVER STREET 2/2/2009
BUILDING PERMIT of"°oTH qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION x Permit NO: Date ReceivedArco 9 9Ao �9SSAGHUS�� Date Issued: " 0 IMPORTANT:Applicant must complete all items on this page LOCATION_ 12� ;57 Print PROPERTY OWNER/` "/ Print MAP NO: L/ PARCELQ-cbf 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 Alteratio No. of units: Commercial Repair re acement Assessory Bldg Others: Demolitio Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: h1('. ic Phone:�7 -C Address: I I CONTRACTOR Name: d�,4v Lx � I Phone: 5_24`4-57 -0<-t Address: IL &r(I � ? Supervisor's Construction License: 6 j� Exp. Date: Home Improvement License: C �� Exp. Date: 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: $ 2z ��L FEE: $ Check No.: C Receipt No.: �f NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor Location No. Date -0 NORT►q TOWN OF NORTH ANDOVER ►O- P Certificate of Occupancy $ °UAtBuildin /Frame Permit Fee $ '� SIACNUBuilding/Frame Foundation Permit Fee $ P Other Permit Fee $ TOTAL $ Check # CVSJ 21bi0, Building Inspector 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 COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments ' I 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 Main Street Fire Department signature/date COMMENTS s� The Commorrwealth of Hassachusetts De artment o P f Industrialts Office of Investigations ` a 600 W ashinbaton Street tl"' Boston MA 62111 wwrv-mass-gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers A» Hcant Information Pease. Print Le�ibiv ILI J, Name (Business/Organisation/individual): IL Address: ��i�- City/State/Zip:—&a)cAe k Phone Are you an employer?Check the appropriate box: 1•❑ I am a employer with 4. ❑ i aFired aA _ Ty;ON f project(required); employees(full and/or part-time .* ha1 contractor and[sab-contraetorsd' ew construction ?. 1 am a sole proprietor or partner- listn the attached sheet 1 7. ❑ Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. insurance, 8. Demolition [No workers' comp. insurance 5. ❑ weare a corporation and its 9. El Building addition 3.Llrequrr�.d] officers have exercised.their l0-❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers'coma. C. 152, §1(4),and we have no insurance required] t employees. [No.workers' 12.[] Roof repairs • comp, insurance required.) Ll.3•IDOther ��� *Any applicant.that checks boa 9l.must also fill out section below showirtg their workers'camp-nsation poucy mtortnahon. 2 Cont utors that wl o subntit.bo aiitdevii inuicatir:g L`;ey-its Guir:e E:yar„ _n him ouwide cantruc furs rnusi sunmii n nnw am; , +Contractors Iha1 check this box must attached an additional sh-et showing the A f the scb 'on �t it indi -ting scch nye o. and then workker'comp.policy information. t am ann eerplover that is provi&n;workerscompensariori Insurance.for�'employees. informationBelow is the polio,and job site Insurance Company Name: l �' Polic)l or Self-.ins. Lic.9: Expiration Date: .lob Site Address:_ G19 J7' -�a✓e� c� IA�_ City/State/Zip: ' . A Attach a copy of the workers' compensation policy declaration page(showitta theoft CT er and expiration Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition bof criminal penalties of a fine up to 51.500.00 andlor one-yea imprisonment,as well as civil penalties in the r'onn of a STOP WORD ORDER and a fine of up to 5250.00 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 heregp ce . �under the pat v and p naider of penury that the information f mation provided above is Ince and correct Signature: Dates• Phone#: Official use only. Do not write in this area, to be completed by city or town oficiaL City or Town: Permit/Licetese issuin;Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electri l inspector S. Plumbing Inspector 6.Other Contact Person: Phone�: I I I 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 ofhire, 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 inciurii-n.g the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,associati on or other legal entity,employing emplovees. 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 maim„-nance,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 o r local licensing agency shall withhold the issuance or renewal of a license or permit,to operate a business or to construct buildings in the commonweatth for any applicant who has not produced acceptable evidence mf 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 coinpii-eteiy,by checking the boxes that apply to your situation and,if necessary,supply sub-cont-actor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insw-ance. 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 afncia.vit may submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the.affidavit. The,affidavitshould be returned to the city or town that the application for the permit or license is being requested,not the Deparrinent of Industrial Accidents. Should you have.any questions rega-rding the iaw or if you are required to obtain a workers' compensation policy,please call the Department at the nmr-nber,li--d below. Self-insured comm,ani es 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 foryou to fill out in the event the Off of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number whice ch will be.used as a reference number. In addition,an applicant that must submit multiple permit/hcense applications in arty given year,need only submit one afridavit indicatingcurrent policy information(if necessary)and under"3ob 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 licenses or permit not related to any business or commercial venture (i.e. a dog license or permit to burnleaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would iike to thank you in 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 nurnber: The Commonwealth of Massachusetts Dpartment of Industrial Accidents Office of Investidaations 600 'VVasbjn-oqQn Street Boston, MIA G2111 Tel. 4 617-727-4900*ft 406 or 1-g-7 7-MASS.gFE Revised 5-2645 Fax*617-7-7-7749 wUx�'.mass.govldia r1ORTH '9 Town of And No. _ 09 o dower, Mass.42240 ISO 5� COCKIC EWICK y 7 A�RA-rE o �`S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........Awry....... ... . ... ...... ..�... ............................................................... Foundation f✓t/ has permission to erect, buildings on.. �A A. ..... 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 EXPIRES IN 6 MONTHS UNLESS CONSTRLJ ARTS ELECTRICAL INSPECTOR Rough ..... .... ..................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. 1025 FEB 02, 2009 ID: FRED C. CHURCH FAX N0: 978-454-1865 ##2063 PAGE: 2/3 ACORD CERTIFICATE OF LIABILITY °"'21)091 :23 � 02107J200910:23 PRODUCER (800)225-1865 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS G14TS' UPON THE CERTIFICATE FredC.Churvenue HOLDEk THIS CERTIFICATE S NOT AMEND, EXTEND OR H verhoza Avenue ALTER T E COVERAGE AFFORDED BY THE POLICIES BELOW. Haverhill,MA 01830 800-225-1865 INSURERS AFFORDING COVERAGE NAIC# INSURED IN.',U! .i':X.�._ YSS1Lt � d IBJ ti9 "ORki'3CL:C9C`441: Dan Gobeil Home improvement LLC LN_ B 80 Munroe St Haverhill,MA 01830 INSURER Ci INSURER D: INSURER E' COVERAGES 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 TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS, Vm AD L OFJ POLICYNUIY6ER TOUCY�FEDCiIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000.00 AMAGE TO RENTED X COMMERCIAL GENERAL LIABIL ITY REMIS o pence 550,000.00 CLAIMSMADE ElOCCUR MED EXP(Any one person) $5,000.00 A C7ROOD4458 11/24/2009 11124/2009 PERSONAL&ADVINJJRY $1,000,000.00 GENERAL AGGREGATE $2,000,000.00 GEN'L AGGREGATE L IM IT APPLIES PER: PRODUCTS-COMPIOPAGG $2,000,000.00 POLICY PRO- , .ECT COC AUTOMOSI LE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ee acadeM) ALL OWNED AUTOS BODILY INJURY $ SCHEDULEDAUTOS (Per person) HREDAUTOS BODILY INJURY $ NON-OWNED A11TOS (Per ecadenl) PROPERTYDAMAGE $ (Per aecidenl) GARAGEUABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO EAACC $ OTHER THAN AUTO ONLY: AGG $ EXCES"ISRELLAILIABILITY EACH OCCURRENCE $ OCCUR CLA'MSWE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND V y""'.U- OTH- EMPLOYERB'LIABILITY ANY PROPRIE70RJPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERRYEMEER EXCLUDED? El-DISEASE-EAEMPLOYEE E ifyes,describe und¢r SPECIAL PROVISONS below E.L.DISEASE-POLICY L%VT $ OT{8R I DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULDANY OF Tiff ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EMRATION 1600 Osgood Street DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN North Andover,MA 01845 NOTICE TO THE CERTIFICATE HOLDER r1AMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OSUGATION OR LIABILITY OF ANY K7RD UPON THE INSURER,ITS AGENTS OR REPRESENrATTVES. AUTHORIZED REPRESENTATIVE , ACORD 25(200110@) .Client# 30198 mst# 08/09 GL Cat# ©ACORD CORPORATION 9998 i I Dan G0befl Home Improvement LLC 16 Carlida Road Groveland,Ma 01834 g/� q/ (508)451-0493 j�{5P/��p1 C.So 063220 CONTRACT REG. 132182 CUSTOMER:Mary kilpatrick DATE:January,26'h2009 193 Andover Street North Andover PLAN:Remodel Bath THE JOB WILL INCLUDE THE FOLLOWING: PRICE i • Completely demo bath area. • Vent all fixtures properly. • Sheet-rock entire area. • Mud,tape, sand and paint all areas. • Install tile on floor area at a$2.50.00 allowance per square foot. • Install base-board trim door trim and paint. • Install existing sink and provide toilet with a$200.00 allowance. • Permit fee $50.00 • Anything above and beyond said work will be done on a time and material basis @ a rate of$50.00 an hour • Clean and remove all related debris. $250.00 • Deposit of 113 $1,300.00 at contract signing and remaining on completion of job TOTAL MATERIAL AND LABOR $3,875.00 ACCEPTED& ArREEID TO BY: l Mary Kilpatric I AM 67o eil DATE: "�-'U`l DA'R'E: i 01 Board of Building Regulatio sand Standards HOME IMPROVEMENT CONTRACTOR Registration. 132182 Expiration�_11/30/2010 Tr# 278527 Type DBA jqv DAN GOBEIL CONTRAC IT NG DANIEL GOBEIL € 3 � � rrf i 80 MONROE ST. HAVERHILL,MA 01836-155" Administrator -- I Air o mg egulaYiofis a an aImm Construction Supervisor License License: CS 63220 �SExp +on 1/31/2010 T41 15704 .max DANIEL L GOBELL` '' ru• 80 MONROE ST HAVERHILL,MA 01830 Commissioner seg �"-v'Plt"aR.z° k � A � t 06, z .1 1CA . ARDV 01834 I I I 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 I i J , Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. ii Roofing, Siding, Interior Rehabilitation Permits I ❑ 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 1 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 o 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 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 Doe:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Date. TOWN OF NORTH ANDOVER� PERMIT FOR PLUMBIN)d SS4 U This certifies that . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform ... . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of L at. . .. . . . .* N'orth Andover,*Mass*. Fee. . . . .Lic. No..q.f 5.7. . . . . . . . PLUMBING IIS16PI1CTOR Check # Z L6 A, 7981 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or paint) NORTH ANDOVER,MASSACHUSETTS Building Location / /� C ` �' 4�,y�a(C Date Owners Name Permit#- � Type of Occu anc pcjejtc Amount r— New Q Renovation Replacement Plans Submitted Yes � No F1FIXTURES 00DO U U W � r q ]ST PIDQt 1 3RU 4JTiFIDQ2 SIH Z~IDQ2 6IH IIlt 7rg2 - gIIiRj0M (Print or type) Installing.Company Name (�0-j t VKCA-V- t �v LX4, IV*�j Check one: Certificate Address � El Corp. c�U e �l• 4a Farmer. usiness elephone ® Firmtco. 2 97-7 Name of Licensed Plumber --�- i Insurance Coverage: Indicat®type of insurance coverage'byecki chng the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver I the undersigned have been made aware that the licensee of this applicati three insurance on does not have any one of the above Signature Owner 13 Agent I hereby certify that all of the details and information I have s 'tt best of my knowledge and that all plumbing wor d installa on �(or red)m e application are true and accurate to the compliance with all pertinent provisions of the M ac use Pe O under ' Issueb for this application will be in PI of the General Laws. By: ign re License um er Title of Plumbing License City/Town 7 • Cents vu oer j� ❑ APPROVED ro [cE use om r Journeyman Location No. 20 Date i TOWN OF NORTH ANDOVER t �y O w • + ; , Certificate of Occupancy $ -is E<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 04 Building Inspector iiiiiiIIIIIIIINInIII�IIIIIIIIIIhInI1V Staple oldels IIhIIIIIIIIIIINI�IIIIIIIIIIIIIIIBIIIIIIIIIIV i BUILDING PERMIT wNORTH TOWN OF NORTH ANDOVER o °Z., APPLICATION FOR PLAN EXAMINATION 7° X23 Permit NO: Date Received w°Awreo��y4� Date Issued: -Z 0 �SSACHUSE� IMPORTANT:Applicant must complete all items on this page LOCATION �"S ( �,C\& C ---�t�z Q- P P'nt PROPERTY OWNER io�r�1 ��',1��. ctc el ii Print MAP NO: Ui�- PARCEL: ! - ZONING DISTRICT: Historic District yes Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Reside Non- Residential New Building One far' 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 PREFORMED: �v)Qa-. S�\k ^���.S Identification Please Type or Print Clearly) OWNER: Name: Y\ � vkC�� Phone: Address: \ct`i) CONTRACTOR Name: QV-e%uir l VZ Phone: r 8 t-ar1` , v , Address: - f 13+ c-C P��y2 lti3c,.c\�v��. c3,n f�'t A 2,L%a 3 Supervisor's Construction License: OD (,tt�°I g Exp. Date: Home Improvement License: Ian�-a` . Exp. Date: 2l 2-00F3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COAST BASED ON$125.00 PER S.F. VZD Total Project Cost: $ l 1 FEE: $ ) a' Check No.: (,Q 0 sSO Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;S gnature of Agent/Owner Signature of contractor 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 f INTERDEPARTMENTAL SIGN OFF U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COl\k`ME NTS 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 Main Street Fire Department signature/date COMMENTS NORTH Town of _ - 1 No. o dower, Mass., O O LAKE COCFIIC FIE WICK y^ �d ADRATED 7`T E BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT r�K ........... ..� ....�1. /('.a....................... ...... .................� � .... ................................................ Foundation has permission to erect...........%;........................... jUildings on.../ ........ .. . . .��.......�..,*�........ Rough to be occupied as.. x'. .. ...:......./li/�... Chimney provided that the person accepting this permit shall in every spect 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 13 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR. UNLESS CONSTRUC TS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. _f 'y YOU colepl-" Licensedand Fully insured f I DATE: 2/12/2008 I In business since 1982 PROPOSAL SUBMITTED TO: JOB ADDRESS IF DIFFERENT: 8 Four Acre Drive Mary Kilpatrick Burlington,MA 01803 (781)272-7310 193 Andover Street North Andover, MA 01845 978-685-8816 We herebysubmitspeeifications and estimates for. We will remove existing shingles from all areas of main roof and rear extension. Low sloped roof area that abutts rear extension will be strip and replaced. New roof will be installed as follows: • GAF Weatherwatch along first three feet and valleys to prevent ice dam. • GAF shinglemate applied to remaining roof surface. • 8" aluminum drip edge installed along all rakes and eaves. • We will use GAF 25 Yr. Royal Sovereign Fiberglass shingles. • Shingle-over ridge vent will be installed to entire length of main roof. • Protective tarpaulins to be hung around house. • Legally dispose of all construction related debris. Low sloped roof area at rear of main roof will have GAF two-ply self adhesive roof system consisting of base sheet and cap sheet installed to first 6 to 9 feet. Cost: $11,000.00 Additional charges would be as discussed, flashing work to chimney, if needed, and properly connecting side entrance roof into main house. I I� Q I Authorized Signature: � We Propose hereby to furnish material and labor-complete $11,000.�� in accordance with above specifications,forthe sum of. ................................................. PAYMENTTO BE MADE AS FOLLOWS: DEPOSIT- !U1), .) One third when job is started , one third when half done,final third BALANCE: -1 , 6%,dV when job completed. r The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined above. Signature: The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations a 600 Washington Street Boston,MA 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Legibly Name(Business/Organization/Individual): t Rcnk ky\k CCG'C,Q opo(\.j e Q Address: F) J�-uT r-e- Oc 0- City/State/Zip: 63tic\I rt��c�✓� M W Phone#: �1 1 -'l3 l c� Are you an employer? Check the appropriate bog: Type of project(required): I.[TI am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling These sub-cshi and have no employees ontractors have g ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.$ 9. ❑Building addition ' required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their I 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers'co right of exemption per MGL �• 12.E]Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 131-1 Other comp.insurance required.] "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. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: M Mvtvt nSti�� Com,�q.�„I f Policy#or Self-ins.Lic• L`1(0 o 31 Q 0 t2 Expiration Date: Job Site Address: 3 AR�Gyt 4— S 1Y City/State/Zip: cuJ� tvl 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 j 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 DIA for insurance coverage verification. I do hereby certijy under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: ? o Phone#: l 2Z 2 3(O 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#: 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('1)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-contractor(s)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 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. 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 Office of Investigations would like to thank you in 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#6.17-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11F22-06 www.mass.govldia Ep YOU co` e Licensed and fuiiyfnsured DATE: 2/12/2008 i 61 In business since 102 PROPOSAL SUBMITTED TO: JOB ADDRESS IF DIFFERENT: 8 Four Acre Drive Mary Kilpatrick Burlington,ma ossoa 193 Andover Street (781)272-7310 North Andover, MA 01845 978-685-8816 We herebysubmitspecifications and estimates for. We will remove existing shingles from all areas of main roof and rear extension. Low sloped roof area that abutts rear extension will be strip and replaced. New roof will be installed as follows: • GAF Weatherwatch along first three feet and valleys to prevent ice dam. • GAF shinglemate applied to remaining roof surface. • 8" aluminum drip edge installed along all rakes and eaves. • We will use GAF 25 Yr. Royal Sovereign Fiberglass shingles. • Shingle-over ridge vent will be installed to entire length of main roof. • Protective tarpaulins to be hung around house. • Legally dispose of all construction related debris. Low sloped roof area at rear of main roof will have GAF two-ply self adhesive roof system consisting of base sheet and cap sheet installed to first 6 to 9 feet. Cost: $11,000.00 Additional charges would be as discussed, flashing work to chimney, if needed, and properly connecting side entrance roof into main house. 1 Q Authorized Signature: We Propose hereby to furnish material and labor-complete $11,0�0:�0 in accordance with above specifications,for the sum of: ................... PAYMENT TO BE MADE AS FOLLOWS: DEPOSIT: One third when job is started , one third when half_ done, final third BALANCE: --I, C/UU.rJy when job completed. The above prices,specifications and conditions are satisfactory and t are hereby accepted.You are authorized to do the work as specified.. Signature: Payment will be made as outlined above. USI New England 12 Gill Street,Suite 5500 PROTECT. MANAGE. GROW. Woburn,MA 01801 ® www.usi.biz October 29, 2007 I i Gregory S Green G & G Roofing Company 8 Four Acre Drive Burlington, MA 01803-1921 i We are enclosing the renewal of your A/R Workers Compensation policy. Policy Number AWC7003489012007 Effective 10/25/2007 to 10/25/2008 Policy Insurer A.I.M Mutual Insurance Company Please read your renewal policy carefully and let your Account Manager Lee C. Nunes know if any changes or corrections are necessary. In the event of a loss, your rights to insurance coverage will be controlled by the terms, conditions and exclusions set forth by this policy. Higher limits and additional coverages may be available. Please contact Lee C. Nunes if you would like to discuss these options. I We appreciate your confidence in USI and look forward to serving you again soon. i GGROOFI N/2575976/M ECCD Information Concerning Our Fees:Unless otherwise specifically negotiated and agreed to with our client,our professional fees are customarily based on commission calculated as a percentage of the premium collected by the insurer and are paid to us by the insurer.We may also receive From insurers and insurance intermediaries additional compensation(monetary and non-monetary),which is contingent on volume,profitability or other factors pursuant to agreements we may have with them relating to all or part of the business we place with those insurers or through those intermediaries.Such agreements may be In effect with one or more of the insurers with whom your insurance is placed,or with the insurance intermediary we use to place your Insurance.We will be pleased to discuss with you further details of any contingent compensation agreements pertinent to your placement upon your request. GT/e -Pomvreoozcue�cLC! o�✓�aa¢c�z.�ael7a _ . Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration,,106222 Board of Building Regulations and Standards Expiration 7/22/2008 One Ashburton Place Rm 1301 Typs, pBA, Boston,Ma.02108 G &G ROOFING".CO., ,:�___;' <. Gregory Green " 7 8 Four Acre Dr - - --- Burlirigton, MA 01803 "-- Deputy Administrator Not lid w hout signature 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) I it i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 i Building Department i 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 o 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 j Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) j ❑ 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) o Building pp Permit Application a 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 o Mass check Energy Compliance Report o 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 I MASSACHUSETTS UNIFORM APPLICATIO 'FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date p Building Location LJ 'Owners Nam r / Permit#. Y 6- Amount - 7 3 � Type of Occupancy New rl Renovation Replacement Plans Submitted Yes No E] FIXTURES F F S1BOM B!>L4�IVIIVI' 15` BSM 2l�ill~IIDQZ 3MRBM 4MRUR 5MROCR 6MROIR 7M BOOR SIIl<ROCR (Print or type) / Check Certificate Installing Company Name r Corp. _ .� Ad Partner.. Business Telephone 7-- Firm/Co. Name of Licensed Plumber. s Insurance Coverage: a of insurance Indicate the ance coverage by checking a appropriate box: Liability insurance policyLj Other type of indemnity El Bond ❑ Insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts lumb' a hapter 142 of the General Laws. By: ► 51 U&MRsouPOOR Title 1--Type of Plumbing License c Za APPRwn ►cense mer Master Journeyman ❑ APPROVED(OFFICE USE ONLY Date } &O RT A TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SACMUS� This certifies that ... . • • • • • • • • •44A---'�Iol has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the_b5uildings of . . . . .. . . . . .�. . . . . . . . . . . . . . . . . . . . . . ; at . . . . . . . • • • • • • • • • •, North Andover, Mass. Feeb--� Lic. No%a.ua C . . . . . . . . . . . . . . . . . . . . . . i PLU 81 INSPECTOR Check # / 436 Date.....7 0 TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING AMW"W SSA CHU This certifies that ........... -..Tw.. e, haspermission to perform .......... /? ............................. wiring in the building of............. 4.L 7,0.e I.,e--.. .......................... at.......1.1z...4.ve4le........5.=........... .�?rth Andover,Mass. Fee.....3 T....... L i c.No: 0.7 Q& ................. ELECTRICAL INSPEcmR Check # 7527 Commonwealth of Massachusetts Official Use Only Permit No. 76 Department of Fire Services a-� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7 j8�a 7 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant 0 Pa�r Telephone No. Owner's Address $o.� Is this permit in conjunction with a building permit? Yes Q'No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: S�` Com letion o the olloxdn table ma Al—i-41..the Ins ector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets 1 No.of Hot Tubs Generators KVA No.of Luminaires `� Swimming PoolAbove ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of OR Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No.of Waste DisposersHeat Pum umber Tons KW No.of Self- ontarned Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection �? No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or Equivalent Si Ballasts Heaters KW No. asts Data Wiring: Signs BalNo.of Devices or Eg uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications W�rrng: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: a/yd Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCBOND ❑ OTHER ❑ (Specify:) I certify,under the and p nald of pert ry,that the information on this application is true and complete. FIRM NAME: /oma, &17-4e- 1,,--Ie r r,'C LIC.NO.: Licensee: ;,.,as /. 91Ic_ Signature LIC.NO.: 3�6aa� (lf applicable,enter"exempt-in t to license,�};umbex line.) Bus.Tel.No.:6�3 5'3?S i^.z3 Address: Ot f /ah q/.-K d tip N�/ 0 3vsp-3 Alt.Tel.No. 6`s r6t•s�yy *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ -- -- - lr� 1 f �� � � � - 10-� 7 �� L i r� 1 I i �' I ----- _ - The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Workers' Compensation Insurance Affidavit: Bui d s/Cont Applicant Information ractors/Etectricians/Plumbers Name(Business/ Please Print Le ibl t)rganization/Individual): Address: City/State/Zip: Phone.#: F2.[] ou an employer?Check the appropriate box: joyj a employer with 4. (] I am a general contractor and I Type of projeet(required):. es(full and/or part-time).* have hired the sub-contractors 6. 0 New construction a sole proprietor or partner_ listed on the attached sheet. 7• ship and have no employees These sub-contractors have Remodeling i working for me in any capacity, employees and have workers8. 0 Demolition [No workers'comp,insurance comp.insurance.$' 9. 0 Building addition required.) 5. We are a corporation and its 3. 10.[]Electrical repairs or additions El am a homeowner doing all work officers have exercised their myself.[No workers'comp. right of exemption per MGL 11.0 Plumbing rept or additions insurance required.]t C. 152,§1(4),and we have no 12.0 Roof repairs employees.[No workers' 13.0 pd= comp.insurance required.] ;Any applicant that check,box#1 moat also fill out the section below showing their workers'� tian policy information, t homeowners who submit this affidavit iodic tContractors that check this box must attachedt additional am doing all wink and then hire outside contractor,must submit a new affidavit indicating such. employees. If the sub-contractors have employees,theymust g the name of the sub-contractors contractors and state whether or not those entities have provide their workers comp.policy number. I am an employer that is providing workers'compensation insurance f information, or my employees Below is the poUcy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Attach a copy of the workers'compensation policy declaration page(showing tit/e policy number a Failure to secure coverage as re and expiration date). g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a foie up t$$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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office a Investi ,tions of the DIA for insuran a covers a verification I do hereby certify under the pains and penalties of perfury that the information provided above is true and correct Si afore: Date• ' Phone#• _ Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Ins ector 6.Other Contact Person: - Phone#: TOWN OF NORTH ANDOVER NpRTFt APPLICATION FOR PLAN EXAMINATION to ,.++6 3? ° +• ,..,,, OCL 0 p • Permit NO. � Date Received Date Issued: i r �9SS/ICHUS IMPORTANT: Applicant must complete all items on this page LOCATION 113 V-"4 5- Print PROPERTY OWNER MA-pt-y lei C P,4-,Z,cle— 0 Print MAP NO.: !PARCEL: Ur Z ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0 TYPE OF IMPROVEMENT PROPOSED USE Reside ial Non-Residential ❑New Building 5'6ne family 0 Addition ❑Two or more family 0 Industrial EX-Alteration No. of units: 0 Repair, replacement ❑Assessory Bldg 0 Commercial 0 Demolition 0 Moving(relocation) ❑Other ❑ Others: 0 Foundation only DESCRIPTION OF WORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: Phone: �Rr- 1;4/4 Address: /� ©✓�� ST CONTRACTOR Name: 03(/k -A)-0 C- 1Z14« S LLC Phone: Address: �� /� ��L�L,�-� , �✓/� d 0 7F Supervisor's Construction License: �f ys fS� Exp. Date: -3 , /o -s Home Improvement License: 10 G�� .� Exp. Date: 7 ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT. 512.00 PER 51000.00 OF THE TOTAL ESTIMATED COST B SED ON 5125.00 PER S.F. Total Project Cost :$ Z Tx12.00=FEE:$ Check No.: 15 Receipt No.: 0 Page Iof4 Location oo No. Date r � U M011T1y TOWN OF NORTH ANDOVER Certificate of Occupancy $ 1016 qi b+• ,. ,SswCMUSEt� Building/Frame Permit Fee $ —� Foundation Permit Fee $ Other Permit Fee $ I TOTAL $ i f Check # k 204 G (` Building Inspector V TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art L1Swimming Pools 11 Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ � Permanent Dumpster on Site ❑ Private(septic tank,etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fi d Signature of Agent/Owner Signature of contracto Plans Submitted L" Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF-U FORM DATE REJECTED DATE APPROVED PLANNING& DEVELOPMENT ❑ ❑ []Water Shed Special Permit ❑ Site Plan Special Permit El Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance,Petition No: 'Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments k i Water&Sewer connection/Si ature&Date Drivewav Permit Tem Dum ster on site �A4p p ye no_ Fire Department signatureldate Section II Construction Contract of the Contract/Proposal for Mary Kilpatrick and Cara Marshall 05/15/2007 Contract Proposal—Page 6 of 6 i BUSINESS CONDITIONS TO THIS CONSTRUCTION CONTRACT This Contract, dated 5/15/2007 is by and between: Mary Kilpatrick and Cara Marshall 193 Andover Street North Andover, MA 01845 Blackdog project code KILPA-7280-K (Hereafter referred to as OWNER), and I Blackdog Builders, Inc. 7 Redroof Lane, Unit#1 Salem, NH 03079 (603)898-0868 (Hereafter referred to as CONTRACTOR). Work will be performed at: 193 Andover Street, North Andover, MA 01845 (Hereafter referred to as PROPERTY) 1. GENERAL This CONTRACT is for the following work and materials to be performed by the CONTRACTOR on the PROPERTY address shown above. The project is generally described as follows: bathroom remodel (Hereafter referred to as WORK) The CONTRACT consists of this document, any plans, the specifications, the Blackdog client package and the Construction Contract. (Hereafter collectively referred to as the"CONTRACT') 2. PRICE The total price for the WORK agreed upon is $22,985.07. Payment terms are set out below in Paragraph 6.This proposal may be withdrawn by us if not accepted within thirty(30)days. 3. STARTING AND COMPLETION PROVISIONS The WORK will begin on approximately 7/2007 and will be completed, absent unusual or unforeseen circumstances, on 812007 providing this CONTRACT and any related CONTRACT documents are accepted when presented. Projects requiring two contracts (one for construction work and one for bath or kitchen product)will not be slotted into the schedule until both agreements have been executed. The aforementioned dates reflect our present workload. Projects are assigned a slot in our work schedule as they are accepted,on a first come first served basis.These dates may move based on the completion time of the project that immediately preceded yours. 4. PERMITS AND APPLICABLE CODES; COMPLIANCE WITH LOCAL LAW a. All work to be done under this CONTRACT will be in accordance with local, state and county building code. The CONTRACTOR shall obtain all necessary permits and pay all required permit and plan fees from the CONTRACT sum, unless otherwise agreed. The CONTRACT price does not include any fees, which may be incurred to obtain a variance, if required. The CONTRACT price does not include any unbid items required by any local building official to bring the project into compliance with any relevant local, state and county building code. 05/15/2007 Contract Proposal—Page 4 of 4 b. All home improvement contractors/subcontractors working in the state of Massachusetts must be licensed and registered by the Bureau of Building Regulations and Standards. All inquiries concerning the CONTRACTOR should be transmitted to that office. In Massachusetts Blackdog Builders, Inc. operates under License number CS048847 and Registration number 106877. 5. SPECIFIC REQUIREMENTS FOR MATERIALS AND WORKMANSHIP a. This CONTRACT will be completed by the CONTRACTOR in a good and workmanlike manner, using quality materials. b. If applicable, the CONTRACT price includes the following allowances: See allowances under specifications. 6. PAYMENT a. Timely payment by the OWNER of all sums due under this CONTRACT is of the essence to this CONTRACT.The parties agree to the following schedule of payments: Deposit with this contract: $1,149.25 Payment Schedule amounts reflect a Partner Plan credit of$2,500.00 b. Payment Schedule Start of project $2,964.83 Start of plumbing rough-in $2,964.83 Start of electrical rough-in $2,964.83 Start of drywall hanging $2,964.83 Start of floor covering $2,964.83 Start of painting $2,964.83 Substantial Completion $966.79 Completion of Punch List $580.05 c.Allowances for Owner Selected Components Sheet Vinyl Flooring—Arrow Flooring $168.00 d. The CONTRACTOR may cease operations if any payment is not made by the OWNER as required herein, and proceed to collect any balance due through any remedy provided by law. Payments are due when the aforementioned progress milestones have been reached. It is understood that minor adjustments to the payments schedule may be necessary due to the flow of work or delays beyond the control of the CONTRACTOR. e. DEFINITIONS Substantially complete-The space or project is substantially complete when the space or project can be used for its intended purpose and only punch list items remain. Punch list-Work or product that has not been performed or provided. Warranty item-A product or service that has been provided or performed that does not meet or exceed industry standards. THESE CONDITIONS MUST BE ACCOMPANIED BY THE CONSTRUCTION CONTRACT 05/15/2007 Contract Proposal—Page 5 of 5 CONSTRUCTION CONTRACT This Contract is by and between: i Mary Kilpatrick and Cara Marshall hereafter referred to as "OWNER", and Blackdog Builders, Inc hereafter referred to as "CONTRACTOR"for work at 193 Andover Street, North Andover, MA 01845 dated 5/15/2007. This CONTRACT consists of this document, any plans, the Specifications and Business Terms that are enclosed and the Blackdog Builders Client Package.(Hereafter collectively referred to as the"CONTRACT") 1. CONTRACTOR'S DUTIES--GENERAL a. To direct and control the work contracted for in accordance with the terms of this CONTRACT and all applicable codes, laws, and regulations, and as the building permits issued for this project, if any, require. b. To inspect the site, examine the plans and specifications, if any, and supervise all of CONTRACTOR's employees, and to direct the work of all subcontractors selected by CONTRACTOR. c. To maintain the work site in a safe and clean condition, to the extent consistent with the CONTRACT. d. To advise the OWNER promptly if concealed conditions are ascertained which require additional or different work, and to proceed in such event in accordance with this CONTRACT. e. To provide locked storage for any equipment, tools, or other PROPERTY used in the performance of this CONTRACT, unless otherwise agreed in writing. 2. OWNER'S DUTIES--GENERAL a. To provide adequate utilities for the work agreed upon. b. To advise the CONTRACTOR of any condition of the PROPERTY which affects CONTRACTOR's ability to perform. c. To provide secure storage areas for materials delivered to the work site. d. OWNER shall be entitled to make periodic inspections of the work site, provided such inspections do not interfere with the work and can, in the judgment of the CONTRACTOR, be made safely. Any other entry onto the construction site shall be at OWNER's risk. i e. OWNER shall notify his insurance agent of the execution of this agreement and obtain any necessary riders to his current coverage or any locally customary forms of coverage, such as builders risk, to cover OWNER's interests and liabilities during the construction process. f. To perform no work on the project without a written agreement with the CONTRACTOR. j g. To make no agreements with any trades person, subcontractor, or CONTRACTOR'S employees outside the scope of this CONTRACT without the written consent of the CONTRACTOR. I 05115/2007 Contract Proposal-Page 7 of 7 i 3. MATERIAL SUBSTITUTION CONTRACTOR reserves the right to substitute other materials, products and/or labor of equal or superior quality, utility,or similar color. 4. DELAY CONTRACTOR shall not be responsible for delays caused by events beyond the control of the CONTRACTOR, including but not limited to: strikes, war, acts of God, riots, governmental regulations and restrictions. Delays caused by OWNER's failure to make allowance materials selections or caused by the performance by CONTRACTOR of extras or necessary work(as described in Paragraph 6)shall likewise be excusable delays. 5. INSURANCE CONTRACTOR agrees to maintain all necessary forms of insurance to protect the OWNER from liability for any occurrence arising from the performance of this Contract. CONTRACTOR agrees that he shall cover his own employees for worker's compensation and carry general liability insurance, and that all forms of insurance referenced herein shall be with reputable companies licensed to do business in the state where the project is located. 6. HIDDEN, CONCEALED and UNFORESEEN CONDITIONS a. The parties agree that in the event CONTRACTOR discovers a hidden, concealed or unforeseen condition requiring an extra cost that they shall proceed as follows: The CONTRACTOR shall notify the OWNER verbally to expedite agreement as to any charge necessary to correct or cure such condition, and provide a written Work Order (as described in paragraph 7a) as soon as practicable. The parties must agree to such extra charges, or agree to a resolution method, or this CONTRACT may be cancelled by either of them. b. For purposes of this section, a "hidden, concealed and unforeseeable condition" shall mean a condition not readily observable to a prudent CONTRACTOR inspecting the subject PROPERTY for the purpose of performing this Contract. Examples of such conditions can include, but are not limited to; rot under siding; ledge below grade; pre-existing plumbing or electrical work not performed to code and pre-existing mold. c. Any change in the WORK required by building officials assigned to this project, including structural and/or any environmental hazards will be billed as an EXTRA charge to this CONTRACT and paid for by the OWNER as a Work Order. CONTRACTOR may cease operations if OWNER refuses to pay 7. EXTRAS a. Any extra work or materials desired by the OWNER shall be agreed upon in writing and such extras shall become a part of this CONTRACT as if fully set forth herein. Unless otherwise agreed, extra work shall be paid for as performed. Failure of the OWNER to sign a change order shall not preclude recovery for any work performed by CONTRACTOR, and acceptance of said extra work or materials shall be presumed, unless there is written notice to the contrary. b. CONTRACTOR shall advise OWNER, at the time of agreement on an extra, as to any additional time required to perform this CONTRACT. 05/15/2007 Contract Proposal—Page 8 of 8 8. ESCALATION CONTRACTOR reserves the right to pass on additional costs to OWNER resulting from the escalation of the cost of lumber or lumber byproducts. This cost may be passed on only, if after the CONTRACT is signed but before the construction commences, an increase in lumber costs is experienced. The CONTRACTOR must substantiate the change with evidence of the difference between lumber costs at the time of the CONTRACT and lumber costs at the time of construction. Only direct cost differences may be passed on, no allowances for overhead and profit shall be included.Any additional costs will be collected per Work Order(as described in paragraph 7a.). 9. EXCESS MATERIALS ON SITE CONTRACTOR routinely stores extra materials on site to improve efficiency and reduce the likelihood of running out of stock in the middle of a task. Unless otherwise specified in writing all excess materials on site at the end of the project are the PROPERTY of CONTRACTOR. 10. SUBCONTRACTORS a. CONTRACTOR shall select subcontractors as required to complete this CONTRACT. OWNER acknowledges that subcontractors will do various portions of the work. Any subcontractor selected by the CONTRACTOR shall have all requisite licenses for the work to be done by such subcontractor. b. It shall be the duty of the CONTRACTOR to use reasonable care in the selection of subcontractors. Absent objectionable performance by any subcontractor, the selection of subcontractors shall be an exclusive right of the CONTRACTOR. The CONTRACTOR shall require all subcontractors to have workmans compensation and liability insurance in force. i c. CONTRACTOR shall pay subcontractors in a timely manner and obtain from subcontractors any necessary documentation required to release their liens, if any, as the work proceeds.. 11. TERMINATION AND CANCELLATION The CONTRACTOR may terminate and cancel this CONTRACT if any payment called for hereunder is not received as scheduled, provided that notice is given to the OWNER as provided below. Upon such termination, the CONTRACTOR shall have all remedies provided by law, including such lien rights as then apply. The OWNER may terminate this CONTRACT upon the following conditions: a. Failure of the CONTRACTOR, or his subcontractors, to pursue the work contracted for, absent excusable delay, as provided in Paragraph 4 above, for a continuous period of fourteen (14) days, without a written agreement permitting same, such agreement may be satisfied by a single notation to this CONTRACT. b. Failure of the CONTRACTOR to rectify any condition for which building code enforcement authority has issued a citation of violation notice, within fourteen (14) days notice of such violation, unless OWNER and CONTRACTOR otherwise agree. c. Any other failure to perform this CONTRACT required by the terms of this CONTRACT. Contract Pro e 9 of 9 osal—Pa 05/15/2007 P 9 i d. No termination shall be effective unless 10 days notice of OWNER's intent is given as required below, during which time the default may be cured by the CONTRACTOR. e. Deposit monies - Cancellation of this CONTRACT prior to the commencement of work shall result in the forfeiture of any and all deposit monies collected. All deposits are non-refundable. The parties hereby agree that upon such cancellation, the CONTRACTOR shall suffer damages including but not limited to the cost associated with designing and preparing the project for commencement. f. You may cancel this agreement by observing the requirements of The Notice of cancellation you have received. g. If a dispute arises out of or is related to this Contract, or the breach thereof, the parties shall endeavor to settle the dispute first through direct discussions. If the dispute cannot be settled though direct discussions, the parties agree the dispute shall be settled by arbitration administered by the American Arbitration Association under its Construction Industry Arbitration Rules. In the event that arbitration is necessary, the parties agree that arbitration proceedings shall be conducted by a mutually agreed on arbitrator in Rockingham County, New Hampshire. If the parties cannot agree on an arbitrator, either party may file a written demand for arbitration in accordance with the rules of the American Arbitration Association. The arbitration award shall be final and judgment on the award may be entered in any court having jurisdiction thereof. This CONTRACT shall be governed and interpreted in accordance with the laws of the State of New Hampshire. The parties acknowledge that this agreement to arbitrate shall be governed by Chapter 542 of the New Hampshire Revised Statutes Annotated. Either party may, without waiving any remedy under this CONTRACT, seek from any court having jurisdiction any interim or provisional relief that is necessary to protect the rights or PROPERTY of that party, including but not limited to the right to seek liens or attachment. The prevailing party in any dispute arising out of or relating to this CONTRACT or its breach that is resolved by a binding dispute resolution process shall be entitled to recover from other party reasonable attorneys' fees, costs and expenses incurred by the prevailing party in connection with such dispute resolution process. Consumers in Massachusetts shall be required to submit to such arbitration as provided in MGL c. 142A. I Mary Kil ck an rshall Shirley Mason Design Consultant Blackdog Builders, Inc. Notice: The signature of the parties above constitutes an acknowledgement of the agreement between the parties to alternative dispute resolution. Massachusetts consumers may have the right to initiate alternative dispute resolution even where this section is not signed by the parties. h. Unless otherwise agreed in writing, CONTRACTOR shall continue the WORK and maintain the agreed work schedule during any dispute resolution proceedings. If CONTRACTOR continues to perform, Owner shall continue to make payments in accordance with this Contract. 05/15/2007 Contract Proposal—Page 10 of 10 12. ENVIRONMENTAL HAZARDS a. The CONTRACTOR is NOT responsible for the inspection, discovery, abatement or removal of any environmental hazard including, but not limited to: asbestos; mold; lead; radon; ground water or environmental pollution at the work site, unless specifically covered in the specifications. b. In the event that any hazardous material is discovered during the course of construction, the testing, abatement and/or removal shall be the sole responsibility of the OWNER. c. Any additional costs incurred on account of suspension of the construction or changes to the specifications due to a hazard or its removal are the responsibility of the OWNER and will be handled by a Work Order. d. In the event that work does not resume within 30 days of the stoppage, OWNER agrees to immediately pay the CONTRACTOR the pro rated amount of the CONTRACT price applicable to work done up to that point pursuant to the Contract. WARRANTY OWNER warrants that as of the date of this CONTRACT: (1)the PROPERTY(including the land, surface water, ground water, and improvements to the land) is, and will continue to be,free of all contamination, including (a) "oil, petroleum products, and their by-products" (b) any"hazardous waste"as defined by the Resource Conservation and Recovery Act of 1976, as amended from time to time, and regulations promulgated thereunder; (c)any"hazardous substance"as defined by the Comprehensive Environmental Response, Compensation, and Liability Act of 1980,as amended from time to time, and regulations promulgated thereunder,specifically including asbestos and mold; and(d)any other"hazardous substance" (2)the PROPERTY is in compliance with all environmental laws and regulations; and (3) there are no underground tanks on the PROPERTY INDEMNITY OWNER expressly acknowledges and agrees that it will reimburse, defend, indemnify and hold harmless CONTRACTOR, all Sub-contractors, their successors, assigns and employees from and against any and all liabilities, claims, damages, penalties, expenditures, losses or charges(including, but not limited to, all costs of investigation, monitoring, legal fees, remedial response, removal, restoration or permit acquisition)which may, now or in the future, be undertaken, suffered, paid, awarded, assessed, or otherwise incurred as the result of: (a) any contamination, existing in, on, above or under the PROPERTY(including, but not limited to, contaminated soil, mold, buildings, facilities and/or ground water); (b)any investigation, monitoring, clean up, removal, restoration, remedial response or remedial work undertaken on the PROPERTY; and (c)OWNER'S breach of any warranty given herein. 13. WARRANTIES a. The work of the CONTRACTOR, including materials and labor, shall be warranteed for a period of three (3) years, during which period CONTRACTOR shall at its own expense correct any defect arising from its work unless it is a non-warrantable condition as set out in the Blackdog Builders Client Package. That package shall become a part of this CONTRACT as if fully set forth herein. b. Any and all warranties for appliances or mechanical systems shall be delivered to OWNER as the CONTRACTOR receives them. i 05115/2007 Contract Proposal-Page 11 of 11 c. Notwithstanding any manufacturer's warranty of any component, appliance, or system, no action may be brought against the CONTRACTOR on this CONTRACT for the performance of this work, except as provided above. d. The quality of any work in question will be held to the standards issued in the Residential Construction Performance Guidelines—Third Edition published by the NAHB. 14. SEVERABILITY If any portion of this agreement is found invalid or unenforceable by any court, the remaining provisions shall remain in force between the parties. 15. ENTIRE AGREEMENT This CONTRACT consists of the documents defined herein, and constitutes the entire agreement of the parties. It can be modified only by a written document. OWNER acknowledges that he has read and received a legible copy of this agreement signed by CONTRACTOR, before any work was done, and that he has read and received a legible copy of every other document that OWNER has signed during the negotiation of this Contract.. SU ITTED: DATE Shirley Mason 5/15/2007 Design Consultant Blackdog Builders, Inc. ACCEPTED: i� UA DATE:— IV14y Kilpat ck COA,61 ADW)AX DATE: -I ` 5 Cara Marshall 05/15/2007 Contract Proposal—Page 12 of 12 tkORT Town of Andover No. .3 4L 0 dover, Mass., LA COCMICHEWICWICK 00ATED ls� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.......)011?%�Al ........ ......................................................................................................... Foundation has permission to erect........................................ buildings on ..Ifa..... .....0-T.............................. Rough to be occupied as........ ",0>0"7 Chimney .............. ... ...............................................:.. provided that the p9 "acceptt'g'thi--sl::�pei-r-.m-.1 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 EXPIRES IN 6 MONTH ELECTRICAL INSPECTOR' T UNLESS CONSTTRRU S Rough Service .......... ... ........................................................................ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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 Ingpector. Burner Street No. SEE REVERSE SIDE Smoke Der. ASD07/11/2,,, CERTIFICATE OF LIABILITY INSURANCE DATE(l.1/2 YY0066) PRODUCER (603)669-0704 FAX (603)669-6831 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Infantine Insurance, Inc. ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 5125 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Manchester, NH 03108 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3oyce Dunlap INSURERS AFFORDING COVERAGE NAIC 9 INSURED Blackdog Builders, Inc. wsURERA: Peerless Insurance 24198 7 Red Roof Lane Unit 1 INSURERe: Acadia Insurance Co. 31325 Salem, NH 03079 INSURER C' INSURER D' INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABCVE 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IDErW I T R SIR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CBP9969957 07/01/2006 07/01/2007 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TOPRENTED $ 10'00 CLAIMS MADE aX OCCUR MED EXF(Any one Person) $ 5,00 A PERSONAL&ADV INJURY 5 1,000,00 GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS•COMPIDP AGG $ 2,000,000 PRO- POLICYEl JECT LOC AUTOMOBILE LIABILITY BA98604 58 07/01/2006 07/01/2007 COMBINED SINGLE LIMB X ANY AUTO (Ea accident) 1,000,000 1,000,00 ALL OWNED AUTOS BODILY INJURY $ A SCHEDULEDAUTQS (Per Person) X HIRED AUTOS BOOILYINJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT b ANY AUTO EA ACC S OTHER THAN AUTO ONLY: AGG b EXCESSIUMBRELLALIABILITY CU8145733 07/01/2006 07/01/2007 EACH OCCURRENCE $ 1,000,00 X OCCUR FICLAIMS MADE AGGREGATE $ 1,000,00 A $ DEDUCTIBLE b X RETENTION $ 10,000 $ WORKERS COMPENSATION AND WCA006920415 07/01/2006 07/01/2007 X I WC STAiU- DTH - EMPLOYERS'LIABILITY TOR IMR E B ANY PROPRIETORIPARTNFPJEXECUTIVE E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBEREXCLUDED9 If yes,describe under E.L.DISEASE-EA EMPLOYEEI$ 500,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSION$ADDED BY ENDCRSEMENT(SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AGENTS OR REPRESENTATIVES. For Informational Purposes AUTHORIZED REPRESENTATIVE 1 ACORD 25(2001108) FAX: 898-0821 ©ACORD CORPORATION 1988 I ' I f" \ The Commonwealth of Atassachuselts Department of Industrial Accidents Office of Investigations 600 Washington Street z , Boston, rV14 02111 t ,: www.niass.gov/dia Workers' Compensation Insurance:affidavit: Builders/Contractors/Electricians/Plumbers applicant information Please Print Leuitr>� Marne idual): 24,4(w Mdress: 7 91L9 Co-W L.✓ — City:State:Zip: 54G41*A , A/1�, 43 025 Phone.4: A r�yo,,Ja n employer'. Check the appropriate box: Type of project(required): 1. a employer with 4• ❑ I am a general contractor and I 6. C] New construction employees(full andlor part-tune).' have hired the sub-contractors ❑ 1 am a sole proprietor or partner- listed on the attached sheet.' 7. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 4• ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.I officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per`v1GL I I.❑ Plumbing repairs or additions myself.[No workers' comp- e. 152,§1(-t),and we have no I2.❑ Roof repairs insurance required.] t employees.•[No workers' 13.0 Other comp. insurance required.] \ny applicant that clwcks txs I must also lilt out the-wL:tiun below showing their workers'compensation policy information. `I lomeuwncrs who submit this atridavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this hos must attached an additional sheet showing the name of the sub-contractorsand their workers'comp.policy information. i um an employer that is providing workers'c•onrpensation insurance far my employees. Below is the policy and job site i nformadon. Insurance Company Palicy 'torSelf-ins. Lic.`.`:_l✓C// a0G �a©4�/S _ Expiration Date:__ �, lob Site Address: 193 A V?-O l S i City;Statt:1ip: ,'V, 4A1D#a - PIA, Drys- 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 35A of NIGL c. 153 can lead to the imposition of criminal penalties of a Fine up to 51.500,00 and/or one-,year imprisonment,as well as civil penalties in the form of a STOP%CORK ORDER and a tine of up to 5250.00 a dayagainst the violator. Be advised that a copy of this statement may be forwarded to the Office of fnvcstigations of the DIA for insurance coverage verification. 1 do hereby certify anile i and penulties oJ'perjrt thud the information provided above is trite and correct. ature: Gate: I /JJfic•ial u.�'e uul}. !fin out�ur•ite in this rrr�n, rn he�•�„t,pletrd by �•in•,!r frnun�,fftcirrt. �� City or Town: Permitil icense +ssuiog Authority(circle one): t. Board of Health 2. Building Department =.CitylTnwn Clerk i. VtOrical inspector :i. Plumbing inspector 6. Other Contact P^r,:,t Phone 1!: Lima or rggistraU Wand for individul nse only ' Boa*ak I"R lAw RadSlnnga€h before the expiratlAu date. if found return to: NIM H.f-G1 TM- o13 ftard d Buitditig Regulations and Standards One Ashburtari ftce Rm 1301 Boston,Ms.021,08 + oar,�oratlQn , BLA CKDO G BA DAVID BRYA N ! 7 RED ROOF I.N. i Nat valid withon- `gnature f 3ate�n,N}+11`030'f9 pttEy A� :lie Uammw�uuea`U o�/�aeaac/ueefla BOARD OF BUILDING REGULATIONS 1 License: CONSTRUCTION SUPERVISOR Number CS 094515 Birllt�l : P �1959 02X3/201 0 Tr.no: 94515 Re tt `.0 t THOMAS E CARR, 7 WESTWOOD DFfVE LONDONDERRY, 0305 Commissioner I t: 102" 8"- 15-l"_ —40 4.. 38„ 588 3 B 31 ----- 1 n i Steam �I� --- Radiator ---"gyp-- -- I� rclaw- Foot If) ml, Tub \D N _ 01 .SIN �P �V ^�P I � PIPE CHASE 43 Bu 478" 1O8 __9 I 4" -- I KTLPATRICK-MARSHALL BATHROOM REMODEL CH = 90 1/2" All dimensions-size designations given are This is an original design and must not be Desibncd:5/17/2007 subject to verification on job site and released or copied unless applicable fee has Printed: 5/17/2007 adjustment to tit job conditions. been paid or job order placed. L3athroorn-As Built Final Layout Drawing#: 1 Scale:0 1/2',_-- 1' i Y i -- -----...__---102"-- -- ------- 8"- 15 4 - —404 ----- 3 g" - Steam Radiator NO STRUCTURAL C1ow- CHANGES F000 t Tub ,_.. IN »Iv _ i PIPE CHASE -- -438 478" 104 — 914 KILPATRICK-MARSHALL BATHROOM REMODEL CH = 90 1/2" All dimensions.size designations given are This is an original design and nwst not be Designed: 5/17/2007 subject to verification on job site and released or copied unless applicable fee has Printed_ 5/17/2007 adjustment to fit job conditions. been paid or job order placed. Bathroom-Structural Changes Final Layout Drawing#: l Scale:0 1/2"= 1' I i Bury switches { in-'o wall -- --102" Sand-Blast &Point g.. 15:"- —40-.L" --- Radintor �ustom Shelving --tet.. —--- - ---- -----� SHEET Re-Finish VINYL t` Steam Interior 4 FLOORINGExterior Radintor A -IP i 'sof Tub L Claw- /� Repair m existing , KEEP WATER o:! Foot / tT broken PIPES10 Tub j leg N _ _ EXPOSED -1 24" PEDESTAL 10 11 01 -dp — WALL CAB PIPE Replace CHASE – 44-„ — ---470" — Tub 10;" – Fixture –91;'• — (to code) KILPATRICK-MARSHALL Re-Install BATHROOM REMODEL Existing Sconces CH = 90 1/2" Client to purchase antique medicine cabinet All ditnertsions_size designations given are .o 'Phis is an original design and must not be Designed:4/27/2007 subject to verification on job site and released or copied unless applicable fee has Printed:5/17/2007 adjustment to tit job conditions. been paid or job order placed. -_ - -- - Bathroom 04-27-07 final Layout Drawing#: 1 BLACKDOG SKETCHES Job Name: ADDITIONAL INFO PO#: Date I i Building Setback(ft.) Front Yard Side Yard Rear Yard Required Provided Re uired Provides Required Provided Dimension Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq. ft.: NOTES and DATA—(For department use) Page 3(W4 Doe:INSPE rIONAL SERVICES DEPARTNIEN'r:BPFORb105 Crated IMC.Jan.:ooi The followingBuilding obtained is a list of the rmu l i g Depart re4uired fo ►tient Rooting' oofing Sid' a fi(ied out for a apPro pe Siding' Interior Reba Priate o Buil bilitation to be 1 din Permits ° WOrker�Perin Application o photo Co yOmf Affidavit Co H I C COPY of ract And/ ° Floor Plan Or Or C.S.L.Licenses r propos J Addition Or Deed Irate rior Work ° Building Pe Q SurteYed pe itAPplication Plan oto Comp Affidavit ° Photo ° COPY Of pYofH.7. A C. ° COnt ract nd C.S1.License HYdra Crossecti-WElev s ° Mass clic Calc ulations anon plan o f pro check Ener (Ifgpplicable Posed Work I New gY compliance Repo" With w Construetlo (If h Sprinkler plan D(Sin port Applicable) And ' (single an � ° Building Pe d TWO Family) ° Certitied Pro APplicati y o W, 0 of H j C sed Plot Plan Workers And C.SDEQ ° TWO Sets COmP Affidavit'L'Licenses ° °pY of is CaOf lc ulatio�Plans To (One ° Mass Contract (If Applicable)Be Returne check Ener d)to Include Boalf cases if a v Energy Compliance Sprinkler Plan And CANE of Re O or S e copy and ea/s tha�the aPPeci l permit was re port Addres tie PrOpf din Period is over. Quired the To recor R1 n Clerks off- co °«:rvnrFc'r'rrrnnt seavrces nepnRry Must be submits dh v hthe bur d st hen get Lorded the decision fr Add NT roa'I roti at the om the Address: Registry Of Deeds. SuPervisorl Home Imprl ARCHITEC�I Address: -- f. FEE9C//EDtjIE.•1 _ al i� t Bo3T`'� Profess Planninb � pecisiori� Check No conseryadon ature&D wer connection 5� amen P�gr 11 fq Wates 8&Se nor Ft{e emP�umpyter on site Ye 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 o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses Li Copy of Contract o Floor Plan Or Proposed Interior Work i Addition Or Decks ❑ Building Permit Application ❑ 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) New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o 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 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:INSPECTIONAL SERVICES DEPAR'FMEN'r:BPFOR,%1o5 i f f Pm.r 4 nl'4 0 TOWN OF NORTH ANDOVER — 9. PERMIT FOR WIRING 3 CHU Thiscertifies that ........................... ................................................................. has permission to perform ........ —.. ................. ........................................... wiring in the building of.......... 9,IJ -/ '� .... ................................................. .........I....................North Andover,Mass. Fee.... .......... Lic.No. ELECTRICAL INSPECTOR " Check # 5542 I rm(,UIVMUIV WL:AUH UPS ALq&"(,"1jJ k '11 J Office Use only DEPARTMW OF PUBLIC Sg FE1 y BOARDOFFIREPREVF�MONREGULWT'-NS5raM12.0 Perrnit No. / Occupancy&Fees Checked S '� APPLICATIONFOR PERMITTO P ORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MAS CHUSSTS (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) ELECTRICAL CODE,527 CMR 12:00 Town of North Andover Date r The undersigned applies for a permit to perform the electrical woik escribed below. To the Inspector of Wires: Location(Street&Number) Owner or Tenant l Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Ams I Volts Overhead ❑ p l �-----� Underground No.of Meters New Service Amps=Volts Overhead Under round 1 Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total No.of Lighting Fixtures Swimming Pool Above BelowKVA Generators KVA round ound No.of Receptacle Outlets f No.of Oil Burners No.of Emergency Lighting Battery Units i No.of Switch Outlets No.of Gas Burners No,of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pum s . Tons Initiatin Devices No.of Dishwashers Space Area Heating K�ry g No.of Sounding Devices No.of Self Contained No.of Dryers Heating Devices Detection/Sounding Devices KW Local Municipal Other-� No.of Water Heaters KW No.of No.of Connections Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER• hWMItoeCovQt�RZ=t 0)theM#Ments ofMMadL1sftCRnedLaws IhaveaamiWdv bdp[Cd0fSanr1Dd1ktc P CovtdgeoritsgA%WWa tuvalt3Y YFS Ihavt�rrmledvaal;dptoofofsarrtetothe0l YESED NO cltecUxgdr box If3 hayed/laden/d YES plea9eindtc�t6edletype�oov (ry GUER (Pleasespe�y) eu ee C G, WodcroSla<t EWrkdVakrofEbcbcalWck$ tTie of Regl Surx1cr �� F�1 CG / i l o / LioenseNa Liartsee 0/41 0,S -RO 1 I Sim -� ` _ Lio=NoAddm— BusirtessTelNo. 603-49-77—6.Z3 3 d�(dcJv�d�!'✓' ./lJr'• v 3ctS'� 67�/ - OWNER'S INSURANCE WAIVER IamawatethattteLi=wdoesnotha� Alt TCL Na 97� ,26.E anddatmysgnaUecndmpmntffh=mwaitestllistegtluentett oD orvs arialegtliva]a�tastac�madby�C, lLaws (Please check one) Owner M Agent Telephone No. PERMIT FEE$ lona ure o caner or aPn 11E CUMMUIV VVVAL J H Ur'1VAM1(.1JUNCL JN Office Use only DEPAR7MVVT0FPUBIICS4FM BOARDOFFMPREVEMONRE A7701VS527C�1R12-W Permit No. -_- , c Occupancy&Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date rt C✓ tS~ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 3 '11 JC 6',j_. S4 Owner or Tenant /JG r is Owner's Address Is this permit in conjunction with a building permit: Yes No -a (Check App nate oz); Purpose of Building Utility'Authori2t; n No. Existing Service Amps �Volts Overhead E] Underground No.of Meters New Service Amps / Volts Overhead Underground No.of Meters _ Number of Feeders and Ampacity , Location and Nature of Proposed Electrical Work No.of Lighting Outlets :3 No.of Hot Tubs No.of Transformers Total No.of Lighting Fixtures j Swimming Pool Above Below KVA Generators KVA ' round and No.of Receptacle Outlets / No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons 0).of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other No.of Water Heaters KWNo.of No.of Connections Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP ER• Com Rnsxxibthetaqu¢anaiscfl�fC�al�alLaws tzmatLiab�YL>aaalaeR>bCYirtchldu�g txttssubt arialegttiv�lalt YES NO vaBdprocfOfSarrleblheQl YES '— gF�}m � II � of the bmt. `•1 /plea9e tYPe by BOND oum (PkieSp ffy)_0eh e,-4l l a/ as D t Sm / ad kTa:6onDa*tzegues4�d Ratgh r�el & EstQr dvai�e wodc$ �/ Lica wNo. 1116M as /`.. C�I U C s;g�e 7 . l' c�_ tioat�lvo 3 3620 E BusnesTdNa 603- '13 7-6.7-3 3 3aL-3 ALTe1Na (q7a' ,26S -67J/ �'SINSURANCEWANQt;Iamawaetha dr1j=e_ mthm� i sxarneoDwr critsabs=roalegkmhtasmgiiredbyMm hn tlmC nndLaws ry sgr�aue rn lt�pewit app)ica6on wain dlis regtwerr,alt check one) Owner Agent M Signature of Owner or Agelit Telephone No. PERMIT FEE S � I V I ��v � _ ��� _ � - L! —os - OcT�2 y l �� I� I i Date.... o:,•' ``--•'�.�O� TOWN OF NORTH ANDOVER A PERMIT FOR WIRING CHUSf �� 1 This certifies that ./ w�,.... .. ..:................. ........... has permission to perform `. ��/!/. j �.. ..../ �.. ............... wiring in the,building of ....... .l-1 ..1. �.- �................ at.!.�� !..IJ1V`.�`!�`:' �?.; _ North Andover,Mass. Fee.....J !. .li .... Lic. ELECTN�l. � .. .",����:. .. / 1! d, /�/ RICAL INSPECTO�t Check # 7 v 5766 Commonwealth of Massachusetts Utncral use Permit no. Department of Fire Services �k Occupancy and Fee Checked BOARD OF FIRE PREVTNTION REGULATIONS [Rev.11/991 (leave blank) APPLICATION FOR PERMIT TO PERFO �M ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Elect!cal Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5.6.2005 City or Town of: N.Andover To thea ect re offY�ire By this application the undersigned gives notice of his or her intention to pe rm electrlcawor�C descrlbedsbelow. Location(Street&Number) 193 Andover St. Owner or Tenant Mary K�atrick Telephone No. 91- Owner's Address 193 Andover St. N.Andover MA i Is this permit in conjunction with a building permit? Yes !ANO ❑ (Check Appropriate Box) Purpose of Building residential Iity Authorization No. Existing Service Amps ! Overhead ❑ grd ❑ No of Meters New Service Amps / Overhead ❑ Undgrd a No of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: install 2 new outlets where none existing off existing-circuits__. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total _ TransformersKVA No.of Lighting Outlets i I No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool AboveIn- No.of Emergency Lighting grad. ❑ rnd ❑ Battery Unifs No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones 2 -No.of witches o.o - as Burners No.of Detection and Initiating Devices No.of Ranges No of Air Cond. No of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices _ o.o ihwashers-- Space/Area ea mg]WWW oca7 -- Other Municipal ❑ Connection ❑ -N-o.--oDryers Heating Applicances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices of Equivalent No.of Hydromassage Bathtubs No of M otors Telecommunications Wirin Total HP No.of Devices of Equivalent OTHER Att h addi 'oral detail i e ire or s re u ed b the Inspec r o Tres. INSURANCE COVERAGE: Unless waived by the owner,no permit for die performance ce�ectica�wc9r`Ic ma�Issue un�'essfthe licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The ' undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: M INSURANCE ❑ BOND❑I OTHER (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: _ Inspections to be requested in accordance with MEC Rule 10,and upon completion I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME Power Wiring&Emergency Response,Inc. LIC.NO.: A1.7354 Licensee: Stephen Decker Signature ❑ ❑�Q� ,y�� LIC.NO.: (If applicable enter"exempt"in the license number line) Bus.Tel.No.: 1=800-418-3221 Address: 44 Stedman St,Unit 2, Lowell,MA 01851 Alt.Tel.No: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(checkFnl) ownerowner's agent. Owner/Agent !PERMIT FEE $ 50.00 I y t,omn►vnweaitn Of mdssdcnuseua - -- Permit no. _ f. Department of l=ire Services __ r} Occupancy and Fee Checked ' BOARD OF FIRE PRE=VENTION REG TIONS [[Rev 11/991 (leave blank) APPLICATION FOR PERMIT TO PERFO M ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electr cal Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 5.6.2005__ Ci or Town of: _N.Andover �' - - To then ect re o{{G�ire By this ap�lieation the undersigned gives notice of his or her intention to pe rm electrtca�wor�C describedsbelow. Location(Street&Number), 493 Andover,St. Owner or Tenant Ma Kilpatrick Telephone No. rY - -- ------ Kilp trim MAA - ---. 91- Owner's Address _1_93 Andover St. N.Andover _ MA Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box) Purpose of Building residential F' lity Authorization No. Existing Service Amps / " • q'verhead, U grd 4 No of Meters New Service Amps / Overhead ( Undgrd No of Meters �- Number of Feeders and Ampacity � �i,..,_ l � _ -_------_ ' Location and Nature of Proposed Electrical Work: install 2 new outlets where none x�stmg'off e,7tg!g is _ _ F No.of Recessed Fixtures _7No.of Ceil.-Susp.(Paddle)Fans LNo.of Total - - --- ----- ---- - - Transformers_ KVA - - i No.of Lighting Outlets No.of Hot Tubs Generators KVA wi ming - l Above - - -- - - - -y _ _- i .No.ofLighting Fixtures Swimming Pool Above �= In- I No.of Emer enc Lighting- - _ g-_ __ , Battery Uni s �No.ofRe—cepta—cleOutlets No.of Oil Burners FIRE No.of Zones i grad- � rnd � I � No A-Switches -- �No:01 Ga-s�urners-- I No.of Detection and o of Ranges J No of Air Cond. i No of Alerting Devices r— Devices N - I No.of Waste Disposers I Heat Pump I Number Tons !KW No.of Self-Contained I i Totals: j Detection/Alerting Devices CNo:of Dishwashers I-Space/Area Heating K - i Local Municipal ,Other Connection No:of Dryers --_-- --- -I Heating Applicances --—`--— --- --- I KW Security Systems: -- - -- -- - - -- -- - - - -- -- No.of_D_evices or Equivalent No.of Water KW No.of No.of D to oWiring: De ices of Equivalent Heaters SignsBallasts _ _ No.of Hydromassage Bathtubs No of Motors Telecommunications Wiring: Total HP No.of Devices of Equivalent (OTHER: --- ---- --- -- - - Att h addi nal detail i e ire or s re fired b the lnspec r o fires. INSURANCE COVERAGE: Unless waived by the owner,no permit for die performance, e�ec6ica9 wc�rrc ma�issue un�'essrt ie licensee provides proof.of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: ;X j INSURANCE L_i BOND----' OTHER (Specify:) ('Expiration Date) Estimated Value of Electrical Work: _ _ (When required by municipal policy.) Work to Start: _ Inspections to be requested in accordance with MEC Rule 10,and upon completion I certify,under lite pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME Power Wiring&Emergency Response,Inc. - _ - _ LIC.NO.: --A]7354- - Licensee: Stephen Decker - Signature 1` E LIC.NO.: - - - (Ifapphcable enter"exempt"in the license number line) Bus.Tel.No.: 1-8007418-3221 Address: 44 Stedman St,Unit 2, Lowell,MA 01851 Alt.Tel.No: -- - OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally equired by law. By my signature below,I hereby waive this requirement. I am the(check onb) owner owner's agent. wner/Agent ----- - - ----- — - -- - --- - PERMIT-FEE_$ so.00----- - ��.�►�,� Lam+ Q ��/ M-O f l 3647 i i f NORTI{ °• "; , ° TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSUS x This certifies that ............................................................................................. * has permission to perform --X--� ................. .................................................. wiring in the building of... .�........f � 1 � �� -4.. .......................................'.......... at.. .... ........:.............,................................. North Andover Mass. Fee........:............ Lic.Ncf M'.`.`'.. f ................................................................ ELECTRICAL INSPECMR Check # L 27WC0MV0NWFALTH0FM4mag&vm Office Use oonlyyp _ DEPART111Ei 0FPUBLICS4FM ' permit No. dD r BOARDOFFEEPREWWONREGUL4TI011S27a R12-M G Occupancy&Fees Checked APPLICATTONFOR PERW TO PERFORM ELECTRICAL WORK 4 ALL WORK TO BE PERFORMED IN ACCORDANCE wM-1 THE MASSACHUSSTS ELE meAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date O3 - ®2 Town of North Andover To the Inspector of Wires: 4 !I The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) q3 /r/ndp V.e r .f Owner or Tenant Owner's Address Is this permit in conjunction with a buildin P J g permit: Yes No Q (Check Appropriate Box) Purpose of Building 4.P%-&-,?'f;aJ Utility Authorization No. Existing Service Amps/ r Volts Overhead Underground No.of Meters New Service Amps / Volts Overhead Underground 13 No.of Meters Number of Feeders and Ampacity I Location and Nature of Proposed Electrical Work 12C;f 1L A"i 4,1 A—)oa?w l�v,�n_✓� No.of Lighting Outlets No.of Hot Tubs No.ofTrai dw—mrs Total No.of Lighting Fixtures Swimming Pod KVA Above Below Generators KVA ground ground No.of Receptacle Outlets No.of Oil Bumers Na of Emergency Lighting Battery Units No.of Switch Outlets n •C• No.of Gas Burners No.of Ranges 7 No.of Air Cond. Total FIRE ALARMS No.of Zones Tons too.of Disposals No.of Heat Total Total No.of Detection and Tofis KW hdtiatingDevices �o.of Dishwashers Space Area Heating KW No.of Sounding Devices `1 No.ofSetfContained DetectiodSouaiding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER. fln�rdloeCotei�Ptrnr�rttbtitetagrsalla�tsafNl�dr>�Ga�li�►vs � "••�•'�• [ttat aaertLiabliyll�tratoePb�t3�itdtdetg Co►a�ea sias�t�tralec}>rerfa�t ys NO fhatie %Vhdpoaftisanebdre0&:e YES NO Ifjwlla►edtedaeaYF pleaseite>it�ellhet:typeafaoNaa®ebYd�tgthe 111a1— bmc ' NARANAE BOND Q. OM OM 1 v wt s 750" IRMNAME i�O r"c[e r �ec 7-71cllzY C0,17 7�6 c kl L;oasel la /3 h j==. Ta,m<, �� 0SignweL; eNo _E 3 � Be>m>essTelNa -_?79'- 337-- � }� Alea4 , ,VH 0306-0 AlTe1Na � �.25 ►WI�R'Sli�[1RANC� AIVER;IamatuatethattheLiomsedoesuotlt�ettteitseratoeco►geor�stet�tialartutec�adtryM�ac}sselrsCrertaaiLalvvs rd�myssernit�patrt6appficatio�vvai>�thistecgrstet>ec#, 'lease check one) Owner Q Agent o-� Telephone No. PERMIT FEEC—_,), � 1 Location I ' A N wu'M No. as Date I oftNO oT:,� TOWN OF NORTH ANDOVER � w 9 + ; ; Certificate of Occupancy $ �M�SE,�' Building/Frame Permit Fee $ l�,ct �L Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /d ► '� I Check # 150 .0/ 1 / Building Inspector I �• • . TOWN OF NORTH ANDOVER BUILDING DEPARTMENT f I1 i I APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING nx 5 ,,aaww a�r �rz BUILDING PERMIT NUMBER: / DAIS ISSUED:. /�..�./. SIGNATURE: R Building Commissioner for of Buildings Date SECTION 1-SITE INFORMATION LI Property Address: 1.2 Assessors Map and Parcel Number: q 6- Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS B Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: s � Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ a SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT t 2.1 Owner of Record Name(Pri t) n® Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: \� r Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ • 4vyzf ll ,6a✓,7 -eaev Z 730 Licensed Construction Supervisor: Z�� /� y 4.rll �fC/es � � License Number ��/ / Address Expira ion Date ign re .. Telephone r 3.2 Registered Home Immp�provem`ent Contractor Not Applicable ❑ Company Name r Registration Number Address / f / s-/y�F /yI/ Jr�l 03 J/J--2 � Z 7--f � r-^! 07 1e 7 �4 ��// /7 'e/d /� � Expiration Hate SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result j in the denial of the issuance of the building unit. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all a Gcable New Construction ❑ Existing Building V Repair(s) Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: l SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be 'Item Estimated Cost(Dollar)to Com leted b permit a licant , p 1. Building (a) Building Permit Fee s Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 /S S 7 Check Number SECTION 7a OWNER AUTHORIZATI(5N TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief ll R, Prim�,�rame Si ature of Owner/A ent Date NO. OF STORIES SIZE , BASEMENT OR SLAB SIZE OF FLOOR TUVIBERS IST 2ND 3RO SPAN DUvIENSIONS OF SILLS DR%dENSIONS OF POSTS DE\4ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND 19 RTMI)TNC'.CY)NNFCTF.1_)TC)NATTTRAT.C:AC T.TNF FILE No.477 10116 '01 PM 01:55 ID:SCOLNICK IN. FAX:9786920728 PAGE 2 ID VL 1 oAlOTE M 601 PAc-001.o CERTIFICATE OF LIABILITY INSURANCAMATTEROFINFORMATION ROWLER THI8 CERTIFICAT21S ISSUED AS A. Soolnick Ina Aq.noy, ItLc• ONLY AND CONFERS NA RroHTe UPON THE CERTIFICATE 301 Littleton n Road HOLDER.THIS CERTIFICATE DoF$NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. sox 330 Westford NA 01886-9986 INSURERS AFFORDING COVERAGE Phone: 976-692-3330 Fax:918-692-0729 -- INBUReo INSURER A: National t3rnnJS Mutua INSURER 8' —. ._.....—.. ..----. .. INBURERC: Ry�sQ11 C. Sarbeau --- -- "—� 54 Mie root North#ia d NH 03276 INSURER 6: COVERAGES 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 I36UED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DE6CR19£O HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AOORPOATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ----. ...... -- - FiSIICY ILTi. _. . u r LIMITS LTR TYPEOPINSURANCE POLICY NUMBER bA MID Y TE rYY GENERAL LIABILITY EACH OCCURRENCE S1,000,000 A X COMMERCIAL GENERAL LIABILITY D4PF38887 03/02/01 03/02/02 clat_DAMAGE(Anye^enre) a SO_O,OO_O_ }CLAIMS MADE OCCUR MED 10J.000 EXP(Any ont person) S 1 _— PERa ADV INJURYE 1,000,000 — --- — GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.CCOMPIOP AGO S 2 r OOO 1000 _ POLICY X ja0 F1 LOC: FAWOM01911.8 LIABILITY COMBINED SINGLE LIMITMeANY AUTOALLOWN�OAUTOS 8001LYINJURY(Persu+EDULED AUTaHIRED AUTOS EDGILY INJVRYIPer accident) NON•OWNED AUTOSPROPERTY DAMAGE(Pw eco101n1) AUTO ONLY•EA ACCIDENT 11RA06 LIABILITY .«..._.... -- ........_.. ANY AUTO OTHER THAN ---.EA ACG S`. _.-.-- .. AUTO ONLY: AGO ; EACH OCCURRENCE S EXCE@@ LIABILITY - �.. -... _..... -- ATE S l OCCUR I.... AG REG .�CLAIMS MADF- .�_. ...— .S ....._... ...__...... S CoDUCTIBLE —.... .__.. _ _..._._ .__._._... s RETENTION S WORKERS COMPENSATION AND EF.LDISFASE LIMITSQMPL.OYtRB'UASILRY ACCIDENTBE•EA EMPLOYE-POLICY LIMIT S OTHER OWGR ION of OPRRATIONaILOCATIONSNEHICLESIfiXCLUEION@ ADDED BY BNOORBBMENTISPEOIAL PROVISIONS Operation• ususal Drywall Inatallation S Framing. JOB: _193 Andover St. N.AndIDVer, MA. CERTIFICATE HOLDER N AOWTIONAL INSURED;INSURER LETT@R: CANCELLATION IdCGUtA1 SHOULD ANY OF THE AOOVC DESCRISPO POLICIES BE CANCELLED BEFORE THE ExPIRATIO DATE THERlop.THE 18SUtN0 INSURER IMLL HNOEAVOA TO MAIL 10 DAYS WRITTEN ed1k� M4fiuirs NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 50 SHALL 21 Charles 8tseet IMPOdE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THC INAURER•ITS AGENTS OR N, Andover bm 01845 RL'PRB@ENTATIVB@, M&r 3. Sooln ok CTC, ®AC CORPORATION 1888 enne �e_a r�m�► 3Y27 2X l d rac, ,,, fv i Neet t- ® T14 12- I ' n y i Dei oil i /Yc TG Sc Xe o` , North Andover Building Department Tel: 978-688-9545 I DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: �vm�✓sPr (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Mn, x S gg, BOARD OF BUILDING REGULATIONS v; License: CONSTRUCTION SUPERVISOR 1 Number: CS 024730 Birthdate: 11/27/1954 Expires: 11/27/2001 Tr,no: 11339 10%#10d To:' 00 RUSSELL C BARB EAU r 288 LITTLETON RD � i� CHELMSFORD, MA 01824 Administrator HONE IMPROVEMENT CONTRACTOR Registration: ' 13040b E xpiFat ion: 03/06/2002 Type: Individual RUSSELL BARBEAU US ILL BARBEAUi LITTLETON R0. LOT�207 ADMINISTRATOR CHELMSFORD HA 01824 l/ J� I NORTH TLED ® oAndover No. - o� CoCL 0^ dover, Mass., d AOff TEO SS H E BOARD OF HEALTH Food/Kitchen rERMIT T D Septic System n / BUILDING INSPECTOR THIS CERTIFIES THAT..A/tA..2.�......���..�P-44 ... ..C,A\ .R. ... A1?, ... .�4-1.................................... p, A n Foundation has permission to*rest. pd.l.!^.................. buildings on .....�..-1..� A . . 4v`-P_2 cs, ................ Rough . to be occupied as 1`d `Q� �7!!. �I V'S+....... Q� w1N J_Q w g 4-- 0_00 � 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. y, q� �� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final .UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .............................. ........................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. N i 1 I Date. NORTH TOWN OF NORTH ANDOVER 'too PERMIT FOR PLUMBING ,SSACHU$� This certifies that has permission to perform .: . . . . .. plumbing in the buildings of .. ��-. � . . . . . . . . . . . . . . at. ..,..j. . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee`?/.'a. .Lic. No.1. x�&,;,. . . . . . . . . . . . ( � �l ✓ PLUS iy INSPECTOR Check # 6304 MASSACHUSETTS UNIFORM PPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location , Owner Dame Cit K� Q P(�G Permit# 30 y Amount Type of Occupancy New B/enovation Replacement1:1 Plans Submitted Yes No 1:1 ❑ FIXTURES cn SUMME RASEUvr 1ST FIOOR an H.00IR e M ILOOR 4IH FLOOR 5M IDIR sM H> OOR 7MIWOR 813 FLOOR (Print or type) I Check one: Certificate Installing Company Name Ail��F��S— orp. Address ? gr-� L,.,7 . Partner. Yyl ✓t J �:n 7 usr�nes�s Telephone I j�e/a e-j Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the typeffl insurance coverage by checking the appropriate box: Liability insurance policyEl" Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusett tate P and Chapter 142 of the General Laws. By: re of MEMO riumoer Ty5 e of Title Plumbing License � 2 i City/Town rcense um er Master 0---Journeyman � APPROVED(OFFICE USE ONLY t i 1 Location /9,R No. Date 14O;T: TOWN OF NORTH ANDOVER ; F w A i a � ' Certificate of Occupancy $ �+CNus Building/Frame Permit Fee $ � � Foundation Permit Fee $ Other Permit Fee $ o-a TOTAL $ fe9� Check # 1715 5 ding Insptor V re 01 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT NVATE, OR DEMOLISH A ONE O FAMILY DWELLING APPLICATION TO CONSTRUCT REPAIR,REOE OTWO T'1�i8 SCttiOH�1fr��U�Q� BUILDING PERMIT NUMBER: /D� DATE ISSUED: P- X SIGNATURE: (6-� Building Commissioner/I ctor of Buildings Date z SECTION 1-SITE INFORMATION o 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 03 Map Number Parcel Number * 1.3 Zoning Information: 1.4 Property Dimensions: O •- i Zoning District Proposed Use Lot Area(sf) Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Re red Provided 1.7 Water S ly AG.L.C.40. .54) 1•5- Flood Zone Information: 1.8 Sewerage Disposal System: Public Private 0 Zone Outside Flood Zone 0 Municipal On Site Disposal System D SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Yr)A0-Y R)UP.4- K r C,L Name(Print) Address for Service: a ;Signature Telephone O 2.2 Owner of Record: Name PrintO Address for Service: Z M Signature Telephone go SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ `D1AVf- 2ir.4a/ �S' ��{�y� icensed Construction Supervisor. O License Number Addr Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ e C RC-r 10d-G t+lte-Da4L5 /A— / Company Name < 0 6 m Registration Number r 7 c�� � c z 5 9� �y r Address Expiration Date Sian Telephone SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance 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 permit. Siened affidavit Attached Yes.......0 No.......C1 SECTION 5 Description of Proposed Work(check all applicable) New Construction 0 Existing Building r Repairs) 0 Alterations(s) Addition ❑ Accessary_ Bldg. Demolition 0 Other 0 Specify i Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estima.a$Cost(Dollar)to be OFFICL4L USF,ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of ry Construction 3 Plumbing Building Permit fee(a)s(b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total 0+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 054—f I, D,4✓11) Yf V as Ovner/Authorized Agent of subject propertv r Hereby authorize 1-A'e--/z 9 ga S L D ti'4r-'�- LNC to act on Mk behal tatters relative wo t v this building permit application. Sienature of 0N3mer z Date SECTION 7b OWNER/AUTH ZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject propern Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Sienature of Owner/A ent Date t NO. OF STORIES SIZE 13ASEMENf OR SLAB SILL:OF FLOOR TIMBERS 1' 2' 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DiME.NSIONS OF GIRDERS I LI:ICLIT OF FOUNDATION THICKNESS 51LL OF FOOTING X �'IATFRLaL OF CHINNEIEY 1S 131:1LDLNG ON SOLID OR FILLED Li\ND 13[ ILDIN(i CONNECTED TO NATt1RAL GAS LINE BLACKDOG REMODEL DO-35,000 cf enclosed space — - t (MGL G:112 S.60L) BOARD OF BUILDING REGULATIONS 14-Masonry only License: CONSTRUCTION SUPERVISOR G.-14 2 Family Homes failure to Possess 4 Number CS 048847 P ess a current edition of the Uassachusetts State Building Code Birth7ate -064 'is cause for revocation of this license. Expires 0/2l)05 Tr.no: 1575 s Restri�fed 1 G i DAV1D K BRYAN 7 RED ROOF LN#1 (•� eb _L SALEM, NH 03079 Administrator DIG SAFE CALL CENTER: (888)344.7233 --_._ _ I� I i � � ✓�ie �oan��wvz�ura�l7� �✓1�� j y ---'._..-- ---- — ------- Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR i before:the expiration date. If found return to, Registr"bn: 106877 i Board of Building Regulations and Standards � i X2812006 j One Ashburton Place Rm 1301 Boston,Ma.02108 . ;�,�.ppe� �rl�rate Corporation � BLACKDOG BUI�bERBt 16iG . DAVID BRYAN 7 RED ROOF LN. Salem,NH 03079 Administrator I Not vali i, utsigihature - - r, • » • e I -MAD.. CERTIFICATE OF LIABILITY INSURANCE of/08/2 a' PRODUCER (603)669-0704 FAX (603)669-6831 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Infantine Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 5125 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manchester, NH 03108 Joyce McMann INSURERS AFFORDING COVERAGE NAIC# INSURED Blackdog Builders, Inc. INSURERA: Peerless Insurance 24198 7 Red Roof Lane Unit 1 INSURERB: Acadia Insurance Co. 31325 Salem, NH 03079 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINI 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOT TYPE OF INSURANCEPOLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONDATE(MMIDDfYYI LIMITS GENERAL LIABILITY TO BE DETERMINED 07/01/2004 07/01/2005 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $, 100,000 CLAIMS MADE a OCCUR MED EXP(Any one person) $ 51000 A PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000 POLICY JEPROCT LOC AUTOMOBILE LIABILITY TO BE DETERMINED 07/01/2004 07/01/2005 COMBINED SINGLE LIMIT $ X ANY AUTO (Ea accident) 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO E A ACC S OTHER THAN AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—I CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ S WORKERS COMPENSATION AND WCA006920413 07/01/2004 07/01/2005 X TNCSTATU- 0TH- ' EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 B ANY PROPRIETCR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEq S 100,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATI N SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. For Informational Purposes AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 i I `.. t ' The Commonwealth of Massachusetts > Department of Industrial Accidents Office of Investigations ` Boston, Mass. 02111 - ' ' Workers'Compensation Insurance Affidavit Name �1 0 �i0' - Please Print Name: CA Coe I t G d3 oft.l P eL!� I/I-ee -- Location: ��� ,�.Q a C��fi✓ city Ci 4 u ✓!! Phone �3 ! - � $L► I am a homeowner pertoiming all work myself. F7 I am a sole proprietor and have no one woridrig in any capacity ®e'lam an employer providing workers'compensation for my employees working on this job. Company name: ' �� 14, 4.,4_ - Address � �" �, .•., i City , C.- t ,✓• Phone or ' qe-- o? 1 ' Insurance.Co. f r ' � 'I ' �t 1.�'S - Pakv# 00& Company name: i Address City: Phone�k I POYcy# Failure to some coverage as required under Section 25A or MOL 152 can lead to the Imposition of criminal pendtles d,a tine up to*11,500.0D "or one years'Inprfsonrnent_as w4se_dhapmattieshthelmnnfABT.QP.WEINWREO and_a.fkw d.(S1fl0.G0)_aA*agatost ma. I understand that a copy of this statement may be forwerded to the Office of Investigations of the DIA for coverage vertflcatlon. 1 do hereby certly under the pairs and- dlbes of perjury that the inlformadon provided above is bus and coned. Signature Date IWJIK Print name Ptme 4-0 Officid use only do not write In this area to be completed by city or town official' City or Town PemlitAlcensing []Check I immediate response is required ❑ Building Dept 0 L tens#W Board ❑ Selectman's Offke Contact person: Phone#: ElHealth Department ❑ Other i I North Andover Building Department Tel: 978-688-9545 i DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Ili .s I I i i BUSINESS CONDITIONS TO THIS CONSTRUCTION CONTRACT This Contract, dated 10-19-04 is by and between: Mary Kilpatrick and Cara Marshall 193 Andover Street North Andover, MA 01845 Blackdog project code KILPA-5426-K (Hereafter referred to as OWNER), and Blackdog Builders, Inc. 7 Redroof Lane, Unit#1 Salem, NH 03079 (603) 898-0868 Hereafter referred to as CONTRACTOR). Work will be performed at: 193 Andover Street, North Andover, MA 01845 (Hereafter referred to as PROPERTY) 1. GENERAL This CONTRACT is for the following work and materials to be performed by the CONTRACTOR on the PROPERTY address shown above. The project is generally described as follows: Addition of a bathroom on the 2nd floor (Hereafter referred to as WORK) The CONTRACT consists of this document, any plans, the specifications, the Blackdog client package and the Construction Contract.(Hereafter collectively referred to as the "CONTRACT') 2. PRICE The total price for the WORK agreed upon is$38,069.42. Payment terms are set out below in Paragraph 6. This proposal may be withdrawn by us if not accepted within thirty(30)days. 3. STARTING AND COMPLETION PROVISIONS The WORK will begin approximately the last week of February 2005 and will be completed April 2005, absent unusual or unforeseen circumstances, on providing this CONTRACT and any related CONTRACT documents are accepted when presented. Projects requiring two contracts(one for construction work and one for bath or kitchen product)will not be slotted into the schedule until both agreements have been executed. The aforementioned dates reflect our present workload. Projects are assigned a slot in our work schedule as they are accepted, on a first come first served basis. These dates may move based on the completion time of the project that immediately preceded yours. 4. PERMITS AND APPLICABLE CODES: COMPLIANCE WITH LOCAL LAW a. All work to be done under this CONTRACT will be in accordance with local, state and county building code. The CONTRACTOR shall obtain all necessary permits and pay all required permit and plan fees from the CONTRACT sum, unless otherwise agreed. The CONTRACT price does not include any fees, which may be incurred to obtain a variance, if required. The CONTRACT price does not include any unbid items required by any local building official to bring the project into compliance with any relevant local, state and county building code. 10/19/2004 Contract Proposal—Page 4 of 4 d. No termination shall be effective unless 10 days notice of OWNER's intent is given as required below, during which time the default may be cured by the CONTRACTOR. e. Deposit monies - Cancellation of this CONTRACT prior to the commencement of work shall result in the forfeiture of any and all deposit monies collected. All deposits are non-refundable. The parties hereby agree that upon such cancellation, the CONTRACTOR shall suffer damages including but not limited to the cost associated with designing and preparing the project for commencement. f. You may cancel this agreement by observing the requirements of The Notice of cancellation you have received. g. If a dispute arises out of or is related to this Contract, or the breach thereof, the parties shall endeavor to settle the dispute first through direct discussions. If the dispute cannot be settled though direct discussions, the parties agree the dispute shall be settled by arbitration administered by the American Arbitration Association under its Construction Industry Arbitration Rules. In the event that arbitration is necessary, the parties agree that arbitration proceedings shall be conducted by a mutually agreed on arbitrator in Rockingham County, New Hampshire. If the parties cannot agree on an arbitrator, either party may file a written demand for arbitration in accordance with the rules of the American Arbitration Association. The arbitration award shall be final and judgment on the award may be entered in any court having jurisdiction thereof. This CONTRACT shall be governed and interpreted in accordance with the laws of the State of New Hampshire. The parties acknowledge that this agreement to arbitrate shall be governed by Chapter 542 of the New Hampshire Revised Statutes Annotated. Either party may, without waiving any remedy under this CONTRACT, seek from any court having jurisdiction any interim or provisional relief that is necessary to protect the rights or PROPERTY of that party, including but not limited to the right to seek liens or attachment. The prevailing party in any dispute arising out of or relating to this CONTRACT or its breach that is resolved by a binding dispute resolution process shall be entitled to recover from other party reasonable attorneys' fees, costs and expenses incurred by the prevailing party in connection with such dispute resolution process. Consumers in Massachusetts shall be required to submit to such arbitration as provided in MGL c..142A. I M Fy Kilpyatri Shirley Vande ult ( � / Cara Marshall Blackdog Builders, Inc. I' Notice: The signature of the parties above constitutes an acknowledgement of the agreement between the parties to alternative dispute resolution. Massachusetts consumers may have the right to initiate alternative dispute l resolution even where this section is not signed by the parties. I h. Unless otherwise agreed in writing, CONTRACTOR shall continue the WORK and maintain the agreed work schedule during any dispute resolution proceedings. If CONTRACTOR continues to perform, Owner shall continue to make payments in accordance with this Contract. 12. ENVIRONMENTAL HAZARDS 10/19/2004 Contract Proposal—Page 10 of 10 95" SA2R CH = 80"-81" OP CRAWL DBL SPACE OUTLET AC ESS 95" - All 5" -All dimensions-size designations given are This is an original design and must not be Designed: 8/27/2004 subject to verification on job site and released or copied unless applicable fee has Printed: 10/19/2004 adjL.istulent to fit job conditions. been paid or job order placed. 0 Kilpatrick.Marshall-As Built I Fp 1 113rawing#: I Scale: 0 1/2"= I- Permanently i 95 Seal Door S X�IR 3 2" - 6 2" �P rJr _I CH= 80"-81" M o, Build Change Dividing Door Wall Swing M 36" Increase Increase Ledge Hgt. Crawl Space O 'I L1 to 39" to accomodate (to match 24" x 30" with beadboard hgt) Cabinet C n � All diniensions_size designations given are This is an original design and must not be Designed: 8/27/2004 subject to verification on job site and released or copied unless applicable tee has Printed: 10/19/2004 adjustment to fit job conditions. been paid or job order placed. I " Kilpatrick.Marshall - Structural Changes JFP 1 Drawing#: 1 Scale : 0 1/2"= 1' 95" STAIRS 31 2" 632" SEALED DOOR et radiator M '• U a w:" C0 oaf" i v y>g xc MRS CABINET5 Vs_ Cavalier, p M Square edge prof ce) 4 9 Snow White Paint CH= 80"-81" .; 1 - OBW24.30.9 t- ham', r, 2 - L3D-15.12, reduce height to 78", flush to 3 - Tall Filler 96" (1) �' p 4 - Crown Molding 1 3/8 (1) 5- 6" solid stock (1) Kh . 2 7 - scribe molding (3) -" 95" All dimensions-size designations given are This is an original design and must not be Designed: 8/27/2004 subject to verification on job site and released or copied unless applicable fee has Printed: 11/9/2004 adjustment to fit job conditions. been paid or job order placed. Kilpatrick.Marshall-Design Fp 1 Drawing#: 1 _Scale: 0 1/2"- 1' 95" STAIRS 31�"� 632" a;sa;.:yi"y."�p8,.NN s•;1.. -1".?lj��'`3� ....t;�:'�.title' 4 t`�e,&. -" radiator 02 CO i CH= 80"-81" — 1 H m o x ; 95" All dimensions_size designations given are This is an original design and must not be Designed: 8/27/2004 subject to verilication on job site and released or copied unless applicable fee has Printed: 10/19/2004 adjustment to rt job conditions. been paid or job order placed. i Kilpatrick-Marshall -Design Fp 1 Drawing#: l Scale : 0 1/2"= F I i + I I 1 I 1 I II � I I I i �I II i III II it IIIII III 1 I �. .I III I' i I III IIII II � i(�-� III I l i � nr�t}7:k'i *Kr7p rl�l i Ili II I j �:O I III 91 I II I i II I '�t'isrl, ' II I Ili II I I I �� I I. I I II I• I I j, I Iii li I 'lll���lh�lll.l I:i l i I i I. i I I 1 II Note. This drawing is an artistic Designed: 8/27/2004 interpretation of the general appearance of Printed: 10/19/2004 the design.It is not meant to be an exact rendition. Kilpatrick.Marshall -Design Drawing#: 1 - -- ------- I ! I: 1! III II ' i I 1':' � I M1 I I jl III la ti +i I!I Itl I II ! ! I I I I I it I ' it ( it it h Li Iti ill II �'I I{ II i'I I — V I I I ! h I II li I I I i! i 1l•_ !i 1 I� I jll lil I I I� III I:� j Ilt � ti;V1 � 0 Jill x I ' I I., I I I I it II II 11 II 'I (I I I it ! lil I' I I III II it II i I I y�(,ll II II II! II I r n !I' I i_ II I¢ — I I� ,! I i I I I i I II. �i ti I I• jl I: d i jl � I Ill i�l i' 1 L i I I 7—II � t Ii II I II I � 111 1� I I � III I IlI nI ! I'III I I I I II !I I I' ! ��S � � tyI �I17 f II II I li Ili II II II I I1 � '1 11� I II II I� I I � I I III II I.I) i 1�1 y1 17 II i I li Ii I IJ I V I,' I NI ,I I II ' I I' I lI III I jl I I I i! r� ��-` I!i 1 it IIS! I Ii 11 I III II q It li ii I ii ill 1 p I� � I' 1 i II, I I III Ilt II I I I I•i I. II I ry I �II yl Ili� qj Note: This drawing is an artistic Designed: 8/27/2004 inteihretation of the general appearance of Printed_ 10/19/2004 the design.It is not meant to be an exact rendition. Kilpatrick.Marshall-Design Drawing#: 1 Y E ill 1' Ii F IF: II H ISE I 41 is I;i IH 14 Ii Note: This drawing is an artistic Designed: 8/27/2004 interpretation of the general appearance of Printed: 10/19/2004 the design.It is not meant to be an exact rendition. Kilpatrick.Marshall -Design Drawing#: 1 JT 7111 Note: This drawing is an artistic Designed: 8/27/2004 inteip etation of the general appearance of Printed: 10/19/2004 the design.It is not meaut to be an exact rendition. !Yilpati-ick.Marshall -Design Drawing#: 1 MASTER b,ATHROOM - s=3 I r t. I t - Kohler Memoirs Classic Toilet (White) Kohler Memoirs Classic 7" Pedestal Sink (White) .. Vi g " Ginger Curtain Rod Sterling Ensemble Shower Unit 48"x 34"x 75 3/4" (White) (Polished Chrome) Sigma "Salem" Faucet (Polished Chrome) all accessories to match STERLING Product Search Details Page 1 of 1 72120100 ` EnsembleT"', Series 7212, 48" x 34" x 75-3/4" Tile Alcove Shower- Complete Unit Pyr- • 48" shower Made with solid Vikrell(TM) material- no wx - layers to chip, crack or peel -color molded throughout Modular four-piece design moves around corners and through doorways with ease 1. • Tongue-and-groove interlocking joints form �� a seamless appearance and simplify J r installation 151 K Realistic 6"x 6"tile wall surround 1 ` l • Durable high-gloss finish provides a �= " smooth, shiny surface ' x ` • Lightly pebbled, slip-resistant bottom for better traction and safer footing F � Convenient shelves provide generous storage Shaving ledge/foot rest added for comfort 10-year consumer/3-year commercial 1 limited warranty i S.v'*..7f'C_h 13_odluc?s Aqu '; Sterling Plurnbincli I I I ht //www.sterlin lumbin com/onlineeatalo tp� gp g. g/print.jsp'?rescom=professional&item=1343... 9/9/2004 MZ zN r i I ---- �' I. C'OEA�c NR5 rte, 'jM%ft*-18'•NxZL. I t43 1A s �Qctblcz. C-1r1Pc�. I ' £ � 13� i i0, i � Note: This drawing is an artistic Designed: 8/27/2004 interpretation of the general appearance of Printed: 11/9/2004 the design_It is not meant to be an exact rendition. • Kilpatrick.Marshall-Design Drawing#: 1 95" . STAIRS 312'. 63-L" radiator M tb i 09 ` 1 ` ;P M �r s. N 1 �� e N,x a v • - 'd I () - a i H m o N CH= 80"-81" \ kz Yui 1 95" All dimensions size designations given are , This is an original design and must not be Designed: 11/9/2004 subject to verification on job site and released or copied unless applicable fee has Printed: 11/9/2004 adjustment to fit job conditions. been paid or job order placed. Kilpatrick.Marshall-Lighting JFP 1 Drawing#: 1 Scale: 0 1/2"= 1' NORTIy Town of :� _ 4Andover �. �. T J - LAo over, Mass., oZ COC RICHE WICK V 0RATEO PPS` 5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT .... # I. 4..? tV . .. ... ....... ... .... . .............�.......... ................................... ....... BUILDING INSPECTOR Foundation has permission to erect.t! buildings on .....131 .... ..4/ .v. ........O......V....+.�...`.........s..... .. Rough to be occupied as � go#j 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. y l /004 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough 'A4001fm %� ......................... •................................ Service BUILDING INSPECTOR Final I Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE Smoke Det. Date. . NORTH •�"o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING • o� _ _ r SSACHUS� This certifies that has permission to performu* -`M� . -� lumbin in t=-bldin `f . .* .-c k at./� . . . . . . . . . . . North Andover, Mass. ' Fee-3 v.. .o-4—.Lic. No.. . . f PUL MRING INSPECTOR Check # l;7U v i 6330 r MASSACHUSETTS UNIFO M APPLICATION FOR PERMIT TO DO PLUMBING i ('Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location 1qq � /31 'J Date r— w ers Name r` Permit# 3 Amount Type of Occupancy � New 1:3 Renovation Replacement /Plans Submitted Yes ❑ No FIXTURES >a�s�vr LS]C H10((R 211D FLOOR ` �FIDtR 4M It" SM IUM 6IH Hfm ' 7II3 FIDCR i SM HJDM (Print or type) Check one: Certificate Installing Company Name Address Partner. Telephone Business (�rj S — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above -a three insurance signature Owner ❑ Agent rl I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installation ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuset tat lumbing Code an apter of the General Laws. By: tgnaf "useu riumur of Plumbing License Title City/Town License mer Master oumeyman ❑ APPROVED(OFFICE USE ONLY i I Date. aFk � 1 OF Hp RTN 1ti F� '' �� �•' p TOWN OF NORTH ANDOVER ft[ • - ' PERMIT FOR GAS INSTALLATION • o� �i ,SgACHUSEt t This certifies that .r :. . . . .. . - max. . . . . . . . . . . . . . . . . ., f has permission for gas installation . . . .`.�-.. ... . in the buildings . . �,. - ..�-w. . .. . . . . . . . . . . . . . . . . . . • . ;at �'- !� .�s-�-Q -� -c�-' , North Andover, Mass. M oa . Cry. . Fee�1:. . . . Lic. No��` ? ?r ! ! lir ... . . . . . . . S INSPgA Check# 11;7e 1029 I !i I MASSACHUSETTS UNNORMAPPU ATONFOR PERMIT TO DO GAS Ffr MG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �— Permit# 3� Amount$ \2Owner's Name New❑ Renovation ❑ Replacement ❑Plans Submitted ❑ a Cn � w a U 'AO O m x x z O H O C a 00 z N U z F a O A U z a w H a dz WWQ W WW a z a 0 Oo W °o x O x w A t7 a U 4 > A a F O SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type) heck one: Certificate Installing Company Name rT Address ❑ Partner. Business Telephone a,: ❑ Firm/Co. 9 Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No[] If you have checked yes,please indicate The type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑. Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State WwCode an he General Laws. i Signature of Licensed Plumber Or Gas Fitter By: Title ❑ Plumber / SZ�� City/Town ❑ Gas F� r License umber aster APPROVED wFtcE USE oNr.Y) ❑ Journeyman Date. :. Y- r).):7.. `r t f HORTM ° t o? �` TOWN OF NORTH ANDOVER y PERMIT FOR GAS INSTALLATION ` tee .`� • SACHU pp f This certifies that . . :.t. �,r., .�.,�. . .�. .�. . .`f. . . . . . . . . . . . . . . . has permission for gas installation . . .@ .4- .f ^` . . . . . . . . . . . . . in the buildings of . . . IA., (,�. . . . . . . . . . . . . . . . . . . . Y at . . . t. JP. -?�.. . . . . . . . . . . .. North Andover, Mass. Fee. . 3 Q .'. Lic. No../3.Y.j.-?. . . . . .Qo...3..- - ..--.�. . . . ,GAS INSPECTOR Check# o / r 5U 4 k i MASSACHUSEITIS UNIFORM APPUCATON FOR P TO DO GAS FfnPiG (Type or print) Date 2. 12-Li l NORTH ANDOV2ER,MASSACHUSETTS Building Locations 3 A N Do ver S-t- i Permit# S � A 36- Owner's Name mount$ New❑ Renovation Replacement Plans Submitted x a a w 0 U ra F�F a a' W O C N � OO Z F a > d w w � z U z E-4 z a 0 w o w x O w D r� A C7 a U a > A a H O SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5 T H . F L O O R 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR Name or type) C R J IN C �1 Lk(Ab t NA 3 4X1 . Check❑ Corp.Certificate Installing Company Address ?•b , ►✓�x 3°I SA 1e rA N Partner. Business Telephone 1_<?72 IC09— 115 0 Firm/Co. Name of Licensed Plumber or Gas Fitter Rp/y A LX) S AV 14U C INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M) No O If you have checked.L,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass_General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent i hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass chus Sate Gas Co a hapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter Title 0 Plumber 1 -3 4? 7 Tit City/Town Gas Fitter License.Number Master JourneymanAPPROVED(OFFICE USE ONLY)