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HomeMy WebLinkAboutBuilding Permit #468 - 205 CAMPBELL ROAD 1/6/2010Permit NO: r Date Issued: / '`e -fi TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received IMPORTANT: Applicant must complete all items on this page -LOCATION_ (:� j I'Vt D IAF' i Print .PROPERTY OWNER L�br �c`3Se rrt C6�'1 Print MAP NO:/�PARCELZ. ZONING DISTRICT: Historic District yes n Machine Shop Village .yes ; n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building Qne farm Addition Two or more family Industrial Alterafio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic V1/ell ' ` -'-'Floodplain Wetlands - Wkershetl District Water/Sewer oESCRIPTION OF YVORK TO BE PERFORMED: F �_ &+i -+0 It1 C \ ()J0 ,- 1 �A-S , f i �,y(rS c.(O Floes r; n 4, A Q c vG II o -r C P I Oe Identification Please Type or Print Clearly) OWNER: Name:�_Or i C ToS�j_ �-6rrt son Phone: Address: 2oSr— CG M b -e G " Cv54v 0 LL c_ CONTRACTOR Name: (,an }ry Address;0._'. X_ .f :)�3_ �5ail Supennsor's'ConstruOion_License C.S..7$T $:l > Ex Date Home;lmprovementLicense �3o�t Exp T:Date.,3-c�lQ. ARCHITECT/ENGINEER Phone: Address: �-``�T Reg. No. �J - - FEE SCHEDULE: BUU) G PERMIT: $12.00 PER $1000.00 OF THE TOT CaALbs ST/MATED COST BASED ON $125.00 PER S.F. �cl�s Total Project Cost: $ _ 66, 6S 61C'UrA-erSq etc_ EE: $ 'r-3nQ Check No.: Receipt No.: 22 2 - NOTE: Persons contracting with red contractors do not have access to toe ty fund Si nature of Agent/Owner Signature of contract 9 _ Location �!•! .� !1� No. Date — l� Of NORTN TOWN OF NORTH ANDOVER -- L •. 9 > ; ; Certificate of Occupancy $ 'ssACm St Building/Frame Permit Fee $ Foundation Permit Fee $ cit Other Permit Fee $ TOTAL $ Check # 2272 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art Swimming Pools Well Tobacco Sales Private (septic tank, etc. Food Packaging/Sales Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF . t I FnPm DATE REJECTED PLANNING & DEVELOPMENT COMMENTS DATE APPROVED CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Si nature COMMENTS Zoni Board of Appeals: Variance, Petition No: Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/signature & Date Driveway Permit DPW Town Engineer: 'Signature: Zoning Decision/receipt submitted yes _ FIRE DERARTNtENT a t_ocated 384 09990d. 'Street t_ocated at 124 Temp `Dumpster onsite yes t nor Main Street t Frre Department signature/date' '^ 0) W r M T_ N VV 8 1124" v268-11 M Y M 5 Q' Q LL J d m 0=0 i m Co Q T -IN Z f- W M Y M F_W!L N3: Q /z� WZW>. ' 9a. N_ ............................... ZQ��QQ..O..�....... �.. SQO........._((n�2W�J�m I M `'Ut!)WU°QW2 i D ; OIXzcn JX LL °oa. 8- Z 2'W41�_wuw QO�_j `T -- O Mw O� zm�QQ zU _ I _ M �� �,N 05J o Q<°z�m I U w�' m ��YmOUz .11 £ Z O 468„ N ~� Q �- N a fn M M Q r - Co MM co , „Zb CEI) m 0 Hd �ma0 LO II cf) O-- :MoV F- N N = 2 (� Nld NldCo W > tress jL8I'LL rn 3: L_ _ _ _ .....�..m..o U` F- co —. _..__ OYQm z�7�o7 — _ Q��a W Q O�� VZ6 49EM } LL N bo W 0 1 w 8 bb5EEHHM Q U- Q Lo M N 09 ., e Sr_u.7L ng Z, lo .,9E ,91Lti 91£9 k „86L6 N m m m X Cl) CO) m 2 y d � � d '0O Cl CD 0 Z y CL o =• r � � o CL _• y aC -�v o o p CD CD o CL cr�IF CD o CD CL C. CD y' ap y �CD p CO) O CD Z CD � o CD 0 CD 4c c?�o m O -.y O Q y = cm Z (am It c �' m Vl 4 CL .+ n �o m d o y N N O •-►_I O m 1 m a _� O !O! O cc O n... o z5.c C O H oo ' CD y �\ �cc cin <=r ?:3 . O m ti b =CD n ,oam a _ .d.► H l`f O h O, d - QCL CW CL = r^ .y► O = COP)y` cs �m 1 �z =� COD .=ooh m Ca . _ m d� C=L _ O: n� = o m 0 0 0 7 d pO O % pip � n C) O w G r O p� p G O C 0 z O O "' R p 0 O EJ I Omni 0 9 0 c 6:1 H W (? C) J .i . t CAMARA CUSTOM CARPENTRY L.L.C. REG. # 130545 9 Diana Drive LIC. # 078981 Salem, NH 03079 (603)898-8683 Joseph Camara, Owner FID# 02-0515792 Contract Page PROPOSAL SUBMITTED TO: Laurie and Jose Harrison DATE: 8/31/09 PHONE: 978-794-7957 A STREET: 205 Campbell Street CITY-STATE: North Andover M JOB NAME: .Kitchen and Bathroom Renovations JOB LOCATION: Same JOB PHONE: Same DATE OF PLANS: None We hereby submit specifications and fixed prices for: Renovate existing Kitchen, V floor bath and Master Bath to include: KITCHEN: • Demolition and disposal of existing cabinets and flooring. • Necessary plumbing, to code, to update existing plumbing connections at existing locations and to install new fixtures and appliances. • Necessary wiring, to code, to install new appliances, under cabinet lighting, six recessed lights and limited rework. • Patch walls and ceiling as necessary including skim coating existing ceiling (cathedral excluded). • Paint existing walls only. Includes stripping existing wallpaper. • Install new tile floors including necessary underlayment. Total Tile Allowance (materials only)...$5.50 sq ft • Install up to 21 lineal feet of new cabinets. Includes crown, light and base moldings only. Does not include: Upgrades to existing mechanical systems except as noted above, repairing or upgrading any concealed conditions, decorative light fixtures, plumbing fixtures, cabinets, counters or installation of counters, appliances Total Cost $18,993.00 V FLOOR BATH: existing cabinets, fixtures and flooring. Also includes all wall the and wallboard around tub. • Demolition and disposal of exupdate existing plumbing connections and to install new fixtures at existing locations. New white fixtures are • Necessary plumbing, to code, is included and are as follows: one new Kohler Elongated toilet with Seat one new Sterling by Kohler 5' Tub with valve, one new Kohler oval set-in type sink with 8" Kohler Faucet. Includes relocating tub filler and valve to back wall. • Necessary wiring, to code, to install new light fixture and limited rework. Includes new fan. • Install tile backer board around new tub and patch existing walls as necessary. Includes skimming walls and ceilings for touch-up purposes. • Paint walls, ceilings and trim. Includes necessary primer for existing trim finish. • Install new floor tile including necessary underlayment and wall tile around new tub. Total Tile Allowance (materials only)...$5.50 sq ft • Install new vanity. • Replace existing closet door with new six panel door. Does not include: Upgrades to existing mechanical systems except as noted above, repairing or upgrading any concealed conditions, decorative light fixtures, cabinets, counters or installation of counters, Total Cost $15,267.00 MASTER BATH: • Demolition and disposal of existing cabinets, fixtures and flooring. Also includes all wall tile, floor tile and wallboard in shower. • Modify and enlarge existing shower. and to install new • Necessary plumbing, to code, to update existing plumbing connections fixtures at existing locations. New white fixtures are included and are as follows: one new Kohler Elongated toilet with Seat, two new Kohler oval set-in type sinks with 8" Kohler Faucet. Includes necessary copper pan for new 6' x 3'-6" custom shower. • Necessary wiring, to code, to install new light fixture and limited rework. Includes new fan and shower light. • Install tile backer board around new shower and patch existing was as necessary. Includes skimming walls and ceilings for touch-up purposes. • Paint walls, ceilings and trim. Includes necessary primer for existing trim finish. • Install new floor tile including necessary underlayment. Total Tile Allowance (materials only) ... $5.50 sq ft • Install new shower tile, includes walls, floor and ceiling. Total Tile Allowance (materials only) ... $7.00 sq It • Install new vanity. Does not include: Upgrades to existing mechanical systems except as noted above, repairin grading any concealed conditions, decorative light fixtures, cabinets, ounter or installation of counters, Total Cost $18,219.00 Homeowner eowner Contractor Date ,_✓ CAMARA CUSTOM CARPENTRY L.L.C. REG. # 130545 9 Diana Drive LIC. # 078981 Salem, NH 03079 (603)898-8683 Joseph Camara, Owner FID# 02-0515792 Contract Page 2 of 3 MISCELLENEOUSE: • Refinish existing I' floor Bedroom and Den floors. Approximately 431 sq ft... $1,185.25 • Install new cased openings on first floor including finishing (clear stain grade materials) ... $625.00 • Design, build and install, on site, two 4' wide by 7'-6" high (approximate) built-in cabinets with all paint grade materials ... $1,532.00 We Propose hereby to furnish materials and labor -complete in accordance with above specmcatrons, tor the sum or: Fifty Three Thousand Seven Hundred Twenty One dollars ($53,721.00). Payments to be made as follows: 5% down 30% (a7 start 30% Cad mechanicals 30% na completion of tile, 5% upon completion Contractor shall obtain all necessary construction -related permits as required by law: Building, Plumbing, Gas, and Electrical. Owners who secure their own permits will be excluded from the Guaranty Fund provisions of MGL chapter 142A. The following schedule will and will be adhered to unless circumstances beyond the contractor's control arise: Scheduled Start Date Zn&= A> 10 Date scheduled to be substantially completed. ?b_1 t� Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office f Qbns Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, ch t IA. Homeowner's Signature / u"I'd., Contractor's Signature NOTICE: The signaturee5f the parties above apply only to the agreement of the parties to alte ti t esolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by t p ies. Homeowner's Rights: A homeowner's rights under the Home Improvement Contractor Law L chapter 142A) and other consumer protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may a excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). Execution of Contract: The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recission period has expired. Accelerated Payments: A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information: if you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law," contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170, Boston, MA 02116 (617) 973-8787 or 1-(888) 2833757 If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact: Director of Home improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General (617) 727-8400 AND/OR Better Business Bureau (508) 652-4800 (508) 755-2548 (413) 734-3114 Homeowner1"eownerA�-Contractor Date i 0 T CAMARA CUSTOM CARPENTRY L.L.C. REG. # 130545 9 Diana Drive LIC. # 078981 Salem, NH 03079 (603)898-8683 Joseph Camara, Owner FID# 02-0515792 Contract Page 3 of 3 Express Warranty - Is an express warranty being provided by the contractor? No Yes (all terms of the warranty must be attached to the contract) Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement . Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727- 3200 or 1-800-223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. All home improvement contractors and sub contractors shall be registered. Inquiries about a contractors registration should be directed to: Registration Division, Program Coordinator One Ashburton Place Room 1301 Boston, MA 02108 (617)727-3200 ext. 255239 Acceptance of Proposal 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. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. This proposal may withdrawn by contractor if not accepted within days (DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES) Contractor Homeowner Signature(s) <7��� Date of Acceptance: 71, eo,~-wodaa�✓ 'a°ac�ucaelta Board of Building Regulations and Standards -_ HOME IMPROVEMENT CONTRACTOR Registration: 130545 Expiration: 3/22/2010 Tr# 266109 Type: Ltd Liability Corpor CAMARA CUSTOM CARPENTRY JOSEPH CAMARA 9 DIANA DRIVE SALEM, NH 03079 Administrator ,Nlassachusetts - Department of Public SafetN Board of Building Regulations and Standards Construction Supervisor License License: CS 78981 Restricted to: 00 JOSEPH M CAMARA 9 DIANA DR SALEM, NH 03079 ('umtnissi�mer Expiration: 9/23/2010 Tr#: 3486 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 6.00 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ f _�/�j rr{ ,- (,i _,_,, 4nm CMrip61 Address: Po &Y, �q a3 V City/State/Zip: S LP m N 4` Q3 � Phone #:—(, a 3 --" o �3 Are you an employer? Check the appropriate box: 1. [94 am a employer with 4. I am a general contractor and I employees (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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other 'tiny appilleant tr, at ciieeirs wx r? must &iso sill out the section below showing tLh- w is . � ; b . o ers' 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 sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site information. p Insurance Company Name: % KAUG kr Pm n; ccs . Policy # or Self -ins. Lic. #: (r j< V c U a Li (o A I 0 D q Expiration Date:��� Job Site Address: r9-0�_ CCIM061 l JZJ City/State/Zip:p, AxJ -er mA-- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form 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 yjd th) pains and penalties of perjury that the information provided above is true and correct LO ,�- -9°/ Z� - aG g 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 #: +l ---- Information _ - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 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 021.11. Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 12/28/2209 15:01 FAX 603 898 8269 FOY INSURANCE SALEM =RD CERTIFICATE OF LIABIL PRODUCER 603.898.6320 FAX 603-998,8269 Foy Insurance Group - Salem 130 Main St - Suite 103 Salem, NH 03079 Terri Truhn INSURED Camara ustom (:arpentry, LLC 9 Diana Drive Salem, NH 03079 4001 T + INSURANCE DATE (M M/DD/YYYY) 12/28/2009 TH13 CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, INSURERS AFFORDING COVERAGE MAIC # INSURER A; Western World Ins Group 03132 INSURER 8; Maine Mutual-MMG Insurance Co. 15997 INSURER c: Travelers Indemnity Co INSURER D; INSURER E: - MtKAGF — 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 VWHICH 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 POLICIES, AGGREGATE LIMIIS SHOWN MAY 11AVE BEEN REDUCED BY PAID CLAIMS. OF SUCH NSR ADD'L TYPE OF INSURANCE POLICY NUMBER PpLlCY EFFEcnvs POLICY EXPIRAnON LIMITS GENERAL LIABILITY NPP2211027 03/01/2009 03/01/2010 EACH OCCURRENCE $ 1F.000100( 000 00( X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 50,00( CLAIMS MADE a OCCUR nr"I$ MED EXP (Arty ono person) 5 5 1 t30t A PERSONAL & ADV INJURY $ 1, 000 00( GENERAL AGGREGATE S 2.000.00( GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG $ 1 000 00( POLICY CT LOC / AUTOMOBILE LIABILITY KA 0113476 02/20/2009 02/20/2010 COMBINED SINGLE LIMIT $ ANY AUTO (EesccickNu) 500 00[ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY (Per person) $ B X HIRED AU708 X NON BODILY INJURY $ -OWNED AUTOS IPereumenl) PROPERTY DAMAGE S (Per mcf;w9no GARAGE LIABIUTY AUTO ONLY . EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG 9 EXCESSIUM BRELLA LIABILITY EACH OCCURRENCE $ OCCUR GAINS MADE AGGREGATE 5 S DEDUCYIBLE $ RETENTION $ S WORKERS COMPENSATION AND 6KUH0246N10609 03/24/2009 03/24/2010 X 1= OTH- F.MPLOYERS' UABIUTY rR C ANY .CUTIVE E,LH EACACCIDENT $ 100,000 FICER/RIETOREXCLUDEIE If yea, deeulEe utdor E.L. DISEASE . EA EmPLOYEE 100000 SPECIAL PROVISIONS below E,L, DISEASE - POLICY LIMIT III 500, 000 OTHER DESCRIPTION OF / VEHKXES I EXCLUSIONS Lori & lose Harrison 205 Campbell Street N. Andover, MIA I SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER MALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUY FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AG'ENTB OR REPRESENTATIVES. AGORD 26 (2001108) OACORD CORPORATION 1988 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 Doc:.Building Permit Revised 2008 a 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 ,i❑' Building Permit Application ,/❑ Workers Comp Affidavit r C.S.L. Licenses Ju Photo Copy Of H.I.C. And/0 ,/❑ , Copy of Contract o/❑ Floor Plan Or Proposed Interior Work N��,-❑ Engineering Affidavits for Engineered products : All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit NOTE p 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 ❑ Proposed Work With Sprinkler Plan And 'Floor/Crossection/Elevation Plan Of 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 Sets of Bu Plans (One To Be Returned) to Include Sprinkler Plan And ❑ Two Set 9 Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ ce Report Mass check Energy Comp Enn veered products ❑ Engineering Affidavits forg NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building permit Revised 2008 Date... 1l...a.. I.Iq....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that...4-'..L ................................................ has permission for gas i stallation!�'�.., �'r? in the building f �-� � !�i�?..... 1................................................................ at... G 1:....... , North Andover, Mass. Fee..tQ..t'..-...... Lic. No.... ....... M.............................................................. GAS INSPECTOR Check # �d 0 n , C> cS� 53 2 INZ- - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE SEPT._9, 2014 PERMIT # G TYPE OR PRINT CLEARLY JOBSITE ADDRESS 1205 CAMPBELL RD. OWNER'S NAME I JOSE HARRISON OWNER ADDRESS JOSE HARRISON I TE 978-761-3300 IFAX OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL ® RESIDENTIAL NEW: El RENOVATION: ® REPLACEMENT: PLANSSUBMITTED: YES® NO® • -LIANCES -1 FLOORS- nF=-nFw- F=-!����IFFw-- m ��I - • WHOTEMII!!ninn� Ali ' � n�n�!n �� I�i►�in��,�i�a�' INFRARED 'In!llilllili�l'�■[i LABORATORY• MAKEUP AIR UNIT IWIw-IFw- I Fw-:n�inF=-iFWFWF I �!!�N-WAM POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT FMFM-FMWFM- F=- F,F=-W1W Wh[ Ir l LINVENTED ROOM HEATE- nen �I!Ii INSURANCE COVERAGE have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [:] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [:] OTHER TYPE INDEMNITY E] BOND Ej OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Ej AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicatL7V� ll P rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ROBERT WHITE LICENSE # SIGNATURE MP [21 MGF ® JPE] JGF [j LPGI E] CORPORATION ®# PARTNERSHIP ®# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY I DANVERS STATE MA ZIPJ 01923 TEL 1-800-322-6628 FAX I I CELLI EMAIL r The Commonwealth of Massachusetts Department of Industrial Accidents = Office of Investigations e 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Information— Please Print Le;;ibly _Applicant EasternPropane Gas, Inc Name (Business/Organization/Individual): Address: 131 Water St City/State/Zip: Danvers, MA 01923 Phone #: 978-750-6500 oyer? Check the appropriate box: Type of project (required): FAreTama with 45 4. [] 1 am a general contractor and I have hired the sub-contractorsfull 6 ❑ New constructionoyer and/or part-time).* on the attached sheet. 7. Remodelinlisted ❑ g2.❑ I amasoeproprietor or partner- These sub -contractors have g. Demolition ship and have no employees working for me in any capacity. cmployees and have workers' 9. [] Building addition [No workers' camp. insurance comp. insurance.' 5. � We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. insurance required.] t right of exemption per MGL e. 152, §1(4), and we have no 12.❑ Roof repairs 13.© Other Gas Fitting & Fuel Supply employees. [No workers comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a neje affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the name of the sub -contractors 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 job site information. Insurance Company Name: Safehold Special Risk, Inc — Polic # or Self -ins. Lic. #: EWGCD000080614 Expiration Date: 031 1512015 Y n 'n �Uh CC i^^ (� (�, l � I ��✓1 i City/State/Zip:nc�-A n tJ� Ae 1M� Job Site Address: C y5 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date)./ b Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form 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 pail san penalties of perjury that a information provided above is true and correct. Phone #: 978 bUbbUU 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 S. Plumbing Inspector 6. Other Contact Person: Phone #: NH477156 �I--�(R� �IVJJ LI CERTIFICATE OF LIABILITY INSURANCE DATE (MMW) 3/13/20142014 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 Commercial Lines - 800-990-7465 (CA DOI # OG13561) Safehold Special Risk, Inc. CONTACT NAME: Donna Desharnais PHONE FAX IC No Ext : 603-559-1361 AIC. No): 855-529-7684 AIC, ADDRESS: donna.desharnais@safehold.com INSURER(S) AFFORDING COVERAGE NAIC # 230 Commerce Way, Suite 230 Portsmouth, NH 03801 INSURERA: HDI -Gerling America Insurance Company 41343 INSURED INSURER B Eastern Propane Gas, Inc. INSURER C P.O. Box 1800 INSURER D INSURER E: 2000000 Rochester, NH 03866 INSURER F: COVERAGES CERTIFICATE NUMBER: 7441964 REVISION NUMBER: See below 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. ACCORDANCE WITH THE POLICY PROVISIONS. INSR ADDL SUER' POLICY EFF POLICY EXP LTR TYPE OF INSURANCEISO POLICY NUMBER MMIDDIYYYY MMIDD/YYYY LIMITS A i X I COMMERCIAL GENERAL LIABILITY EGGCD000080614 3/15/2014 3/15/2015 EACH OCCURRENCE S 2000000 CLAIMS -MADE %� OCCUR DAMAGE TO RENTED REMISESIEaoccurence S 250000 i MED EXP (Any one person) S 5,000 PERSONAL& ADV INJURY S 2000000 1 GEN'L AGGREGATE LIMIT APPLIES PER: j :GENERAL AGGREGATE S 2000000 PRO - POLICY jEa j ;LCC i PRODUCTS - COMP/OPAGG S 2000000 OTHER: S A � AUTOMOBILE LIABILITYCOM3I'IED EAGCD000092214 3/15/2014 3/15/2015 Sli iGLE LIMIT S i Ea ac derd; 2,000,000 i X ANY AUTO SOCILY INJUR`! (Per person) S I ALL OWNEDj SCHEDULED • AUTOS _i AUTOS BODILY INJURY ;Per accident} S NON-OWNEDPROPERT HIRED.>UTOS DAMAGE S AUTOS ?erac idant` UMBRELLA LIAR i •' OCCUR EACH OCCURRENCE ; S i� EXCESS LIAR CLAIMS .MADE. I AGGREGATE I S DED I 1 RETENTION S S A ;WORKERS COMPENSATION EWGCD000080614 03/15/2014 03115/2015 ER X STATUTE O'R_- LAND EMPLOYERS' LIABILITY Y I N' 1 ANY PROPRIETORiPARTNER/EXECUTIVE r E.L. EACH A CIDENT S 1,000.000 OFFICER/MEMBER EXCLUDED? I N NIA �` ,(Mandatory in NH) E.L. DISEASE • E.4 EM?LO'!EE: S 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS belowE.L. DISEASE -POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of coverage CERTIFICATE HOLDER CANCELLATION Any city/town in Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MA AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ACORD 25 (2014/01) t itvs cenfrate replaces .ar•nfa!wi 7111 310 .,,-M an 7/1320141 @ 1988-2014 ACORD CORPORATION. All rights reserved. }I : R d {3SN3311, \ ., � ,2-m_ . uj _ . w . �"j CL e» ,: LL -,..Z LLj 1 - \k = - _ » \W u < . p L - m Au @. � V) - ?« uj 2 2 q » : Z \ \ - ^ 2: @ x : °� m } im y , - � V 10770 Date .... U��.�� ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ` has permission to perform SGA n�ez- .. ................................... ................. :............................................. t plumbing in the buildings of-� 1AR , �G,J ........................................................................................ at ....... ::. ...... L `7 ti V —rA, North Andover, Mass. Fee... .........''..... Lic. No. 2. ......`.................................................................................... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY iU v MA DATE' / Y ( PERMIT # lbil� JOBSITE ADDRESS OWNER'S NAME SUS rte, S"o ✓1 I POWNER ADDRESS D a%rr is 1 /� /� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL © RESIDENTIAL ©' PRINT CLEARLY NEW: El! RENOVATION: � REPLACEMENT: PLANS SUBMITTED: YES ® NO 01 FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM E A _{ € DEDICATED GREASE SYSTEM 11L_ (' DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) K115CHEN SINK LAVATORY ROI U,F DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL jWrM[M WATER PIPING OTHER F I 1 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES UTNO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME a / I LICENSE SIGNATURE MPD JP Q CORPORATION FIJ#©PARTNERSHIP D# y LLC I COMPANY NAME �,�,�� / nz S ADDRESS yV/ . CITY /yrl.-� ---�- - -_ _ _..__f STATE M.q _ ZIP TEL S�O 6 FAX L6 CELL C� EMAIL - ;3ri 1 lS _Nn I■ w W lb rJ The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations quo 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): %:kp7 r7e! /j Address:_ Br-oc, ,g,l City/State/Zip: lye7,,, 1-!,4 d / 90 / Phone 6l S S Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. El am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. FFI am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. []Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.] f employees. [No workers' 13. [J Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I -Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form 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. X do hereby certo under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: %()" / / 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 #: "u Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 permitilicense number which will be used as a reference number. In. addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit 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 Massarliv.,sPtts Department of Industrial ,Accidents Mee of Investigatiions 600 WasW gtoan Street Boston} MA 02111 TO, # 617-7274900 ext 406 or 1-877 AMSS.A.k'B Revised 5-26-05 Fax # 617-727-7749 www.mass,govldia 0. 0 Date .... �a...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that- `.. /f.......... . has permission to perform ............. .................. plumbing in the buildings of ... t`:f-u . ..:f ............... . at ...... ..... , North^Andover, Mass. 01 am Fee". � ..... Lic. No...iL,�,.� _! ...` _''r. 1,�:......... . PLUMBINGifNSPECTOR Check # 41�- 8hi. 61 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ��}} / Date Building Location c7��S CArntQbc/1 Rb Owners Name Permit # 7 Amount /, A' Type of Occupancy. �( -eS/A9ex I �hej N New Renovation P Replacement Plans Submitted Yes No Fi TITRF.0 (Print or type) 7� Installing Company Name-pilwyc '/rode T xwznb'�/G�j�%e "Jy Chec one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber:– {� 6we'-1 d Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond a Insurance Waiver: I, the dersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I Owner El Agent n 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 performe under Permit Issued for this application will be in compliance with all pertinent provisions of the Masusetts SJate Plu ng Code and Chapter 142 of the General Laws. By: re l �o en um r Title Type o g License City/Town �-7APROVED (OFFICE USE ONLY icense um er M a ster Journeyman • i i ilk ......................... • , ------------------------- MMMMMMMMMMMMMMMMMMMMMMMMM ms"TMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM� MMMMMMMMMMMMMMMMMMMMMMMMM 1.,,MMMMMMMMMMMMMMMMMMMMMMMMM MMMMMMMMMMMMMMMMMMMMMMMMM (Print or type) 7� Installing Company Name-pilwyc '/rode T xwznb'�/G�j�%e "Jy Chec one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber:– {� 6we'-1 d Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond a Insurance Waiver: I, the dersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature I Owner El Agent n 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 performe under Permit Issued for this application will be in compliance with all pertinent provisions of the Masusetts SJate Plu ng Code and Chapter 142 of the General Laws. By: re l �o en um r Title Type o g License City/Town �-7APROVED (OFFICE USE ONLY icense um er M a ster Journeyman F' i Date........ ...... ...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................... has permission for gas installation, .,-� ............... in the buildings of . .......................... at North Andover, Mass. Fee.-.- Lic. Nil, 6)�'l .. . ......... ....... . GAS INIEC'TOR Check# -/4-/ �O, 7095 MASSACHUSETTS UNIFORMAPPLICATON FORPERVIlT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date /—/2-/0 Building Locations �G-(JJ L�n� �� �V Permit # 76 �S Amount $ Owner's Name �i �C)�V New ❑ Renovation Replacement ❑ Plans Submitted ❑ x SUB -BA SEMEN T BASEM ENT 1S, . FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. 8TH. FLOOR FLOOR (Print or Name _, Address O Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check ole. I have a current liability Insurance policy or it's substantial equivalent. Ye No ❑ If you have checked yes, please indicate the type coverage by checking the appropriatex. Liability insurance policy ❑ Other type of indemnity 1:1 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 Gas Code and Chapter 142 of the General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber /SD d 7 ❑ Gas Fitter License Number ?Er Master ❑ Journeyman �' � w z Q s w o Q s C z F- � F F I 3 c �D J m > O Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. ❑ Firm/Co. INSURANCE COVERAGE Check ole. I have a current liability Insurance policy or it's substantial equivalent. Ye No ❑ If you have checked yes, please indicate the type coverage by checking the appropriatex. Liability insurance policy ❑ Other type of indemnity 1:1 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 Gas Code and Chapter 142 of the General Laws. APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber /SD d 7 ❑ Gas Fitter License Number ?Er Master ❑ Journeyman �' Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ! 2 This certifies that.' ..*`� .:..:............:........... .............................. has permission to perform._. ��- -�� . ....-�� �� � ................................ G_.� ,.-,�-� wrong in the building of..........1�.................................................................. at l� . , North Andover, Mass. Fee..: < .......... Lic. ............ ✓ .......r.,.:........ ELECTRICAL INSPECT ' Check # 9209 Ie (,ommonwea& o/VaMacLetti Official;2' Usse Only IER cc�� c7 Permit No. / 2 d — 2epartment of Jim Sevvices Occupancy and Fee Checked /Gry BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 55227 CMR 12.00 (PLEASE PRINT IN INK OR TYP ALL IN" TION) Date: /— /1? 10 City or Town of: ;;. /4 6fat/Pf,; 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) . a OS eq rn P // k - Owner or Tenant J tryp ghn-tSan Owner's Address Telephone No. Is this permit in conjunr6::t�l- ejn with abuil ing pelrmit? Yes � No ❑ (Check Appropriate Box) Purpose of BuildingZ/ y¢ / Utility Authorization No. Existing Service � Amps /20l2yO 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: 0 0 n r4 p� 7 - Completion Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot. Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting BatteryUnits No. of Receptacle Outlets 19 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 8 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons J.K.W,.......... ..... ..... of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connection E] other No. of Dryers Heating Appliances Kir Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: r Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ,�.7� (When required by municipal policy.) Work to Start: —lQ— 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the ins o%f� d penalties oferju%y, that the information on this application is true and complete. FIRM NAME: A-6011 0 C s 1a1 LIC. NO.: 1.,'56 Licensee: ,Woo R,P,, i Signature LIC. NO.:3S7elyz- (If applicable, enter "exe t" in th licen number 'n e.) Bus. Tel. No.: Address: (� dh'�O �`/irk e171:2—Alt. Tel. No.• _ *Per M.G.L. c. 147, s. 57-61, securi ork 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 PERMIT FEE: $ Signature Telephone No. fig-a-J2� e/z- OK- r 1 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aicant Information Please Print Lepibl' Name (Business/Organization/Individual): Address: r v City/State/Zip: O/ 2 Phone #: 5j Are you an employer? Check the appropriate box: I am a employer with .S 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors '. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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 sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. [ / /� % Insurance Company Name:_ Policy # or Self -ins. Lic. #: Expiration Date:: Job Site Address: yr tC� City/State/Zip: & • l/1 0� 0 (�y.5 Attach a copy of the workers' co pensation 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 W 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. Ido hereby certo yonder ;he pain ,4 and pengKes of perjury that the information provided above is true and correct. Phone #: — "'2n., -3,— -�' 7 �,ep Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 #: MORTGAGE -PLOT PLAN EK SURVEY 1NQ iD TGAGOR r RESS OF PRINCIPLE BUILDING DEED REF' PC. PLAN, REF. DA T>~ OF INSPECTION 6 7111 441. or . fit@ or m 0... spectlon ras Prrpvrrd w ; .. �r edit' form paps purpo•a and b not. to '�� 1 FURT e4 uppoonn.04 autwy� E7t ,,! VE,Y RT Y;_ ra OPINIOi PCbitty for dama e! oD� AUDEI�' Outbudd e by Myone olher >�an theersaf • h an cld rgNo. 3$8ao oh th W h ita .� 'zoning to to d mortgagor.' - `.. �'�EGtSf a of ma) KATION TCM LANA b pivp t't,' '01ftWtEon (Abawd o� the 1 ■� r`roP�y 1• a7d d not rapraverlt d p .e e�rprr shown are of to be otan o y �Y theft J. n ollon y Une•, 4bid for th• ec ablitfirnent of Rood In•urana Rnte Y. PROFES5IONAL ure/s and aocer•ory tsotthelocd no enchroachm*US It ray ocroos 4". d Arso. "b4. �Mmthv flood Hazard. Federal Flood r. kc ,> U 4' Date.-f..!�........�..... 0 NORTM TOWN OF NORTH ANDOVER �g PERMIT FOR GAS INSTALLATIONI This certifies that ............... cc has permission for gas installation ... ! .�. �_.......... . in the buildings of .. f v : : !. ? .. . ....................... . at .' .f ....:..-Z. .. ................ North Andover, Mass. Fee.. Lic. No./ .... ; .... .......................... GAS INSPECTOR WHITE: Aoolicant CANARY: Building Dept. PINK: Treasurer UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING tvvrc><n A1111JUVILK, MASSACHUSETTS Date �„� ,e /,? 19 9e Building Locations C�OS— C�.QrfeE LL /Re Permit # Py Owner's Name Amount �D2 ; 9f ;Zi cS U/7 New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ 0 Nameor type) ���/C � r, Check one: Certificate Installing Company f Address U./ CI I-7(�Ge- /-�U ness Telephone 6 ✓_ D K 7 / Name of Licensed Plumber or Gas Fitter ❑ Partner. Firm/Co. INSURANCE COVERAGE Che hone: I hake 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. ('hark one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 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 Gas Code and Chapter o he General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber // 9� ❑ Gas Fitter License ( um er Master ❑ Journeyman z x F e G z W w x m U W m z --t;4 w : > = C SUB-BASEM ENT BASEMENT 1ST. FLOGR 2N D. FLOG R 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7T 11. FLOOR s T III F L O G R Nameor type) ���/C � r, Check one: Certificate Installing Company f Address U./ CI I-7(�Ge- /-�U ness Telephone 6 ✓_ D K 7 / Name of Licensed Plumber or Gas Fitter ❑ Partner. Firm/Co. INSURANCE COVERAGE Che hone: I hake 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. ('hark one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 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 Gas Code and Chapter o he General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber // 9� ❑ Gas Fitter License ( um er Master ❑ Journeyman