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HomeMy WebLinkAboutBuilding Permit #828-12 - 194 SUTTON HILL ROAD 5/18/2012BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 8`'2�� Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER . -i e Les , w. ( 0 /^ Print "MAP NO:" li' PARCEL � ZONING DISTRICT: Historic. District yes.no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family �'R 1�C� �c'Ie— r eLID Zs - 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 Identification Please Type dr Print Clearly) OWNER: Name:�c..-.� e 1�� 5 , ,�� ly Phone: q `i ArlrlrPc-q• i -R J, CONTRACTOR' Name:_ Address:6cc�c. T . Phone: L�N 9- —td i e --,c. . vl-- C& S'uP ervisor s Construction Licenser C S~ C Q 3 36 5 Exp. Date: Home Improvement License Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULD/NG PERT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER SY Total Project Cost: $ /Q MFEE: $ /�� Check No.: /'�`/ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access th g a Signature:o ,_gent/Owner Signature of contractor e�4�p -��.� �s �'R 1�C� �c'Ie— r eLID Zs - V Identification Please Type dr Print Clearly) OWNER: Name:�c..-.� e 1�� 5 , ,�� ly Phone: q `i ArlrlrPc-q• i -R J, CONTRACTOR' Name:_ Address:6cc�c. T . Phone: L�N 9- —td i e --,c. . vl-- C& S'uP ervisor s Construction Licenser C S~ C Q 3 36 5 Exp. Date: Home Improvement License Exp. Dater ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULD/NG PERT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER SY Total Project Cost: $ /Q MFEE: $ /�� Check No.: /'�`/ Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access th g a Signature:o ,_gent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Taming/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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments d Water & Sewer Connection/signature & Date Driveway Permit k DPW Town Engineer: Signature: Locatea 364 US ooCI Street F.,IRED,EPARTMENT=Temp!Dumpster on yes'_ no, L6cated,at'1124`Main;st�-eet: 'Fite Departmentsi' nature/date _ _ Y_._. _ COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21 A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Pemiit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (if Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location ' N A, �/xY No. Date Check # 25316 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ o? Foundation Permit Fee $ Other Permit Fee $ TOTAL44 $ 1, �j�uilding Inspector wEN U.' ,t,K L k -k -KN 11 ,x.1_31,0 56 Pleasant Street Methuen, MA 01844 Phone/Fax: 978-688-3944 Company Email: Dave@DavidReitanoRemodel.com Proposal Date: 4/4/2012 Submitted To: Ms. Elaine Lostimolo 194 Sutton Hill Rd. N. Andover Mass. 01845 Home: 978- 682-8070 Work: Mobile E-mail Job location - Job Description: Bathroom Remodel We herby submit specifications and estimates for: Bathroom Located on first and second floor will have toilet and vanities removed All debris will be removed from job site. Electric will be salvaged completed recently by others.. Tub and shower will be salvaged,.. valve and shower head will be replaced. Floors in both bathrooms will have new the installed. Walls in tub and shower area will be refinished with a sprayed on finish. New vanity's, counter tops ,sinks and faucets will be installed ,.including upgrading drains and water supplies. New toilets (2) will be replaced in locations of previous. Above total price $10,670.00 I "• *Contractor is responsible for allowances mentioned, anything that exceeds these allowances - Homeowner is responsible for. *Homeowner is responsible for paint and stain *Please review this proposal carefully for any items which may be missing. Contractor is not responsible for items not mentioned here. *Please do not hesitate to contact us if you h ve any qu ion Thank you for considering us for this project David Reitano Workmanship Completely Guaranteed/Sullivan Insurance (Please sign and return one copy) Signature: I r Date: J'.1112 -o ] 2 Signature: Date: I -ouc Safet, W massac',usattmen s - Depart o, ?u�j Hoard c' Butiding 10'equiations and Standards License: C—"23365 41, DAVID REITA46 56 PLEASANT STREET METHUEN NA 01844 f.'o-mmissioner 12/.04/2013. 01 ANY �s iaecs �an Dffi= a., HOME IMPROVEMENT CONTRACTOR Registration: lo8782 Type: RUP Expiradorr 8/2512012 Private Corporatio DWREfTANO REMODEL &-BUILD David Reitan 56 Pleasant St Methuen, MA 01844 Undersecretary ACORD. CERTIFICATE OF LIABILITY INSURANCE 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 12/05/20111 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paychex Agency Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 150 SawDrive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR grass 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Rochester, NY 14620 X CLAIMS MADE El OCCUR! MED EXP (Any one person) $ 5,000 INSURERS AFFORDING COVERAGE INSURED INSURER A: AmGUARD Insurance Company David Reitano dba David Reitano Remodeling and — Building INSURER 8: 56 Pleasant Street INSURER C: Methuen, MA 01844 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 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR DATE IMM/DDfYY1 LIMITS GENERAL LIABILITY A DABP201902 EACH OCCURRENCE _ $ 1,000,000 COMMERCIAL GENERAL LIABILITY 12/01/2011 12/01/2012 FIRE DAMAGE (Any one fire) $ 50,000 X CLAIMS MADE El OCCUR! MED EXP (Any one person) $ 5,000 PERSONAL ADV INJURY $ Included __GREGATE GENERAL AGS 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO jFCT f7 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT �ANY AUTO (Ea accident) $ (�I ALL OWNED AUTOS I--- BODILY INJURY $ SCHEDULED AUTOS (Per penton) BODILY INJURY _ . HIRED AUTOS NON -OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ -----, -__.. .-...- -.-------— - (Per accident) • GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN _� ACC $ ^ $ AUTO ONLY: AGG EXCESS LIABILITY_ I EACH OCCURRENCE $ i..... OCCUR CLAIMS MADE AGGREGATE _ $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- I OTH- EMPLOYERS' LIABILITY TOEr. uMLTsl . I_ ER_ E.L. EACH ACCIDENT S EL DISEASE - EA EMPLOYE_—._._...... E.L. DISEASE - POLICY LIMIT -- $ OTHER I DESCRIPTION OF OPERATKONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Lowe's Companies Inc. and any and all subsidiaries are named as additional insured as respects to General Liability. LETTER: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN • `' L� NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE AWKIL) Z5-5 (nas) 0 ACORD CORPORATION 1988 ACORDM CERTIFICATE OF LIABILITY INSURANCE 0719/MMIDD/YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COMPANIES AFFORDING COVERAGE COMPANY AMGUARD PAYCHEX INSURANCE AGENCY, INC. 150 SAWGRASS DRIVE CO BANY ROCHESTER, NY 14620 INSURED DAVID REITANO COMPANY C DAVID REITANO BUILD & REMODEL 56 PLEASANT STREET METHUEN, MA 01844 COMPANY COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. D LT TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MMIDD/YY) POLICY EXPIRATION DATE (MMIDD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR PERSONAL &ADV INJURY $ OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BOY $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ $ OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY DAWC226669 06/11/11 06/11/12 X WC STATU- OTH- EL EACH ACCIDENT $ 100,000.00 THE PROPRIETOR/ (NCL PARTNERSIEXECUTIVE OFFICERS ARE: X� EXCL EL DISEASE - POLICY LIMIT $ 500,000.00 EL DISEASE - EA EMPLOYEE $ 100,000.00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE. HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY R PROVISIONS, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �r iI Contact"Terson: x x v ° A or. •cam w" ° CQ AG w CLQ w a w w U) w" O. U n: u. z w A w_ c4 co v) a x H VD W �r W U y L L O \ IS�Np N Y`� ,.cmJ co •O� eat N W _N ep O c o ac rt+ N m O � COZ w oao CD :`-mc m : CL 0 `amt �_ c.=oc ~+ m •ul .E t i � V L C.2 O:C C CL m� O' W i0i y0 = $ a$ m F. 4 2 O O L _o Z o d O y � C cm ca p 'C O CO O O ' mm cm CD � O � 3 O �CD O � O � O � In - Co y C /� Q � C cc vca J .a dO y�r c Z CD C.3 CO) O C C CL CO2 o m c •cam C2 O N c O V Qc , m c o O ca= E W4 m C O O �= w : •� V o goN c 0 Co c� IS o ts CD a x H VD W �r W U y L L O \ IS�Np N Y`� ,.cmJ co •O� eat N W _N ep O c o ac rt+ N m O � COZ w oao CD :`-mc m : CL 0 `amt �_ c.=oc ~+ m •ul .E t i � V L C.2 O:C C CL m� O' W i0i y0 = $ a$ m F. 4 2 O O L _o Z o d O y � C cm ca p 'C O CO O O ' mm cm CD � O � 3 O �CD O � O � O � In - Co y C /� Q � C cc vca J .a dO y�r c Z CD C.3 CO) O C C CL CO2 W I • a � 't �. � n. 1 � 0 t; 0 0 W Z, m .. W21 t 0 z 0, z ° -• ti 1 w w � a to • z 't �. � w 1 � 0 t; W W Z, t 0 z 0, z ° -• ti 1 w � a Z 0 z 0 Z o k z Z z w < L r 7 /{ k 0 1 K w I M i Iuu t U z W t W w z O< Z u z z 0 J H z N Z i 0< M J O Y _' � } • 1 W w. u w I p0 L 0 a F- s : .= o� Z Lr L z W ►' w 0 •t't'11' w x Z 1 w M S �c NEI • z 't �. w 0 t; 0.� J t I ti 1 w r Z W z 0 Z o k z Z z w < • Z 0 /{ k 1 N w r M i Iuu t U z W t W w z O< Z u z z u J H z N Z 0< M J O Y _' > } K u w I p0 L 0 a F- 1 : .= o� Z Lr L z W ►' w 0 •t't'11' w x Z 1 w M d M 0 u u c K cc 0 wj Jel w , a+� = o r w w w IK- u M L W M' .. �✓dY , ';d J u < K O . } w L L w < L O k L w;y* o i J I- O S �c NEI N W O M a 10 I- 0 L 0 V a t t L 0 O K a o1 w rp p �� 4•t.•' fit"'"! „ o .# k iekl t r t^ k•� ti • 't �. w t; 0.� J t I ti 1 w r Z W z Z o a z Z z < • Z 0 /{ v w r M i Iuu t U W t w z O< Z u z z u J H z N 0 0< M J O Z _' > M O w I p0 L 0 a 1 : .= o� Z Lr tot w 0 •t't'11' w o Z 1 N W O M a 10 I- 0 L 0 V a t t L 0 O K a o1 w rp p �� 4•t.•' fit"'"! „ o .# k iekl t r t^ k•� ti • 't �. w t; t ti 1 Z W z o a z A Z _' > M O w I p0 L 0 a : .= o� Z Lr w 0 w 0 w o Z wj Jel w , a+� = o r w w w IK- u M L W M' .. �✓dY , ';d u < Z w . } w L L w < L O k L w;y* Location No. =2 q3 Date ' t TOWN OF NORTH ANDOVER Certificate of Occupancy $ ;W;s <�' Building/Frame Permit Fee $ *5 Check #% 18619 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ _..-- /y/W ( L/ Building Building Inspector 1.1 jProperty Address: 1.2 Assessors Map and Parcel Map IMumber Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Ld Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G L.C.40. 34) Pubfic ❑ Private 0 1.5. Flood Zone Information: ZODe Outside Flood Zane 0 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 ar,a, a >ivi'l A- rMVIMK 1 Z V W 1'1 J Karr lr/AU MUlilY,M) AGENT 01, 1 L . 1 Z:71-) --1 v U 2.1 Owner of Record Name (Pnn) Address for Service : Signature Telephone Na a Pnnt Address for Service: T- 1 SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable C Licensed Construction Supervisor: Address Signature Home Improvement Contractor c A Telephone License Number Expiration Date Not Applicable 0 /635"7 Registration Number � I / % 113� Expiration Da S4 SECTION 4 - WORKERS COMPENSATION (XG.L C 152 § 2546) 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. Signed affidavit Attached Yes .......❑ No..: .... 0 SECTION 5 Description of Proposed Work (check an applicable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ ( I Demolition ❑ I Other. ❑ Specify Brief Description of ProposedWork: I SF,CTTON 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building � aw (a) Building Permit Fee 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 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 I, 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 A 1`7i�(®ti^� PPN�e iD11b Si at a of O /A ent Date NO, OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iSF 2 3 RD SPAN DM ENSIONS OF SILLS DIN ENSIONS OF POSTS DUVfENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE IAN Department of Industrial Accidents Office of Invesdgations 600 Washington Street 0 Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaalicant Information Please Print Legibly Name (Business/Organization/Individual): ��wiyAoyl, ,Cu Address:,k City/State/Zip: 41": eP 5� ; Cyg�-,SPhone #• yf2 Are you an employer? Check the appropriate boa: I. ❑ I am a employer with 4. ❑ I am a general contractor and I employee's (full and/or part-time)." have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition l0.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -Any applicant 11181 checks box # 1 must also tilt 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 suck tContractom that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp, policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the polky and fob site information. ,-I . . Insurance Company Name: Policy # or Self -ins. Lic. #:i% y �3�(� Expiration Date: Job Site Address: City/State/Zip:-Aa a- 4ZL,'Vc5 Attach a copy o the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-yearlmprisonment, 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 certify under the pans and penaliks of perjury that the information provided above is true and correct Phone #:i yQ Of tial use only. Do not write in this area, to be completed by city or town oAiai: City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: lniormatiun ailu i115LI U%;Liv]ilia Massacbusetts 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 all 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() 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 Departrnent 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 app licant 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 afiltvit 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www,mass.gov/dia REPAIRS A� CASTRICONE CONSTRUCTION LLC FREE ESTIMATES y CASTRICONE ROOFING & SIDING CO. Telephone: (978) 682-4266 • Fax: (978) 794-0910 MARIO CASTRICONE DAVID MICAL P.O. Box 441, North Andover, Mass. 01845 I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms, and onditions, on premises below described: Owner's Name. Job Address ... �. , GSI . , . ..��:� . . ......... cit �'� . .... State . e5V SPECIFICATIONS u.� .. .. ... ..................`...... .. ......................................................................... ... ...................................... Y�e�z� ...................................... . .............................. .......................... ........................... Materials and labor to cost $ . ; ..Payable . Jj'1 . ,i . .and balance in . .... . monthly installments of $ I . . . . , ... each, payable on ........ day of each and every month thereafter until paid in full (. . . . . . % charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operation. t � IN WITNESS WHEREOF, the parties have hereunto signed their names this.. , , , , , day . . , 20. , Accepted: Signed-' :� 44 . L Owner WNER HAS 3 DAYS IN WHICH TO CANCEL CON3§Adn Signed . . . . . . . . , , , , , , , , , , , , , , , , , , , Owner Per.�. . . . . . . . . . . Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . epresentat e l x w o o w v cn O a 0 o w o aG U x 9 © cG w" V w w aG u p w a ao' m w a c cA o z cn o cn z 0 w w C40) O y E CL r O a COD 0 V CO) O O C cc CLCOD —I W U) W U) 19 W W 19 W U) . G o � G ` O N G CL CL= :goo m c z o Cc o m Ea c�� is ocm E CL. :0Z N >3 f C m N N O O EN m •: CL m ; z yCD co � c � c N G Z O m �CA m HE o Z 0 ' co CL n Q o ` o G o T :m4-3 N 0 W r Oc� .tyii nt O z v •w V m CL CM O . O h O •� _ T w 2 'a a m C H- s lis� z 0 w w C40) O y E CL r O a COD 0 V CO) O O C cc CLCOD —I W U) W U) 19 W W 19 W U) Date .. `'—cs—�� r TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING LSSA`- SEc � i�rEL-Com'-''t� -This certifies that ..:..... . has permission to perform_.. ... . .. .... . plumbing in the buildings of . ........ . ............... . ...... North Andover, Mass. PLUMB1h1Crl'NSPECTOR Check !/ 1,3do �l // 6438 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT O PL UMBIlV (Type or print) NORTH ANDOVER, I Building Location 6 New Ely Renovation ri X� Date �� ez< Owners Name41 Q 0 Permit Amount Type of Occupancy Replacement 13 Plans Submitted Yes r No ❑ FIXTURES (Print or type) Installing Company Name Address h�"b r4ice-A 3 war 4V-ei( j Ch ck o rtificate orp. Partner. FrmlCo. Name of Licensed Plumber: Insurance Coverage: Indicate t^-h■e type insurance coverage by checking the appropriate box: P Liability insurance policy ![ y Other type of indemnity 0 Bond D Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above y 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 perform) under Permit Issued for this application will be in compliance with all pertinent provisions of the Ma ;achusetts Pa"upWg Code and Chapter 142 of the General Laws. y: own ZOVED (OFFICE USE ONLY Type of P pmbing License iz censse NumSer Master Journeyman Claim # Advantage Claim Service's Adjuster Assigneds 2100 ,Lakeview Ave. Dracut, MA 01826 Form of Notice of.Casualty Loss to Buildin Under Mass. Gen, Laws, Ch, 139, Sec. 3B RECEIVED JUN � 2010 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT To: Building Commissioner or v4ard of Health orBoard of Selectmen Inspectgr of bu.LIdiiigv Town Hall address Town Hall., Re: Insured: �, Property address r G Policy #: Loss of: File or Claim No. AD 74,C/3 Claim has been made involving loss; damage or destruction of the above Goptioned property, which may either exceed $1,000.00 or cause lda9s,_Gen._Laws,_Chapter_143, Section_6 to be applicable. If any notice under Mass_ Gen_ Laws, _Ch. �139 Sec. 33 is appropriate please direct it to the attention of the writer—and include a reference to the captioned insured, location, policy number, date of 1Qss and claim or file number, &-A&4//V 6-61/9 EW ' Title: Adjuster on this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 'Signature and date