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Home My WebLink AboutBuilding Permit #289-16 - 206 WAVERLY ROAD 9/4/2015 f(',4",C,o G/' Ir 14ORT1, so ,esti a BUILDING PERMIT ,�: ti°;:r. *.'.• °oma TOWN OF NORTH ANDOVER rC APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 9ss�c►+us�� ORTANT:Applicant must complete all items on this page LOCATION. 20(v WMERL Y t2t� . Wit% A%sbndfx� MA Print PROPERTY OWNER_I Hornars PA C i It'�ARCo 1)'E Print MAP NO: 45-PARCEL:- ZONING DISTRICT: Historic District yes o Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'One family ❑Addition ❑Two or more family ® Industrial WAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑AssessorY Bldg El Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: _)HDMAS � p4i RtC,% A MARCoire Phone: Address: Z Ora W AVERLY A)oR-t-�v kizz ovE��, HA r CONTRACTOR Name: Phone: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMAT COST BASED ON$125.00 PER S.F. ' Total Project Cost: $ i000 FEE: $- Check No.: Receipt o.: NOTE: Persoy coh' ith unre ' tered contractors do not have access to the uaranhof and Signat a of Agent/O a ignature of contractor � I I 4' Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plu!s I� TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ swimming Pools ❑ well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ I COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature r COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments a Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street RE NTTrnum"p s Yyes--�- :a• ,L- L DE �T t_ pt er onjsitga �;, ,. ...a o Lo ted at 124 MainStreet ment s gn�aturld beate��nrztiu� -� } ; �'n 4 J V"�• S �COMMENT�S�----__,. e ,.gid ��..,�..�;•�.,:.�c�,,.. '....,.._'-�".�..._'1 .:. a , �_.`. Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. i Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 i 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i 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/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) 4, Mass check Energy Compliance Report (If Applicable) 4 Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) 4 Building Permit Application 4, Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses � Workers Comp Affidavit 4 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Locatio � �v - Date • - TOWN OF NORTH ANDOVER • Certificate of Occupancy Building/Frame Permit Fee $ C �--- Foundation Permit Fee $ Other Permit Fee $ TOTAL t r_ Check, ✓ 25 3 0 8 Building Inspector Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 2210.100.00 m $ - $ 264.00 Plumbing Fee $ 33.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 33.00 Total fees collected $ 430.00 206 Waverley Road 289-16 on 9/4/2015 Kitchen Remodel I r 1 NORTH - - w - 2 tE � . : ve- .... 0 No. e 1 o1h ver, Mass, wl/f000 C 41�d �RATEO ApP��S S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System ork THIS CERTIFIES THAT ....... .. .........movoBUILDING INSPECTOR . Foundation has permission to erect .......................... buildings onov.. 6........ .... .... ........ . • Rough tobe occupied as ... .r ........... ........................ ........................................................................... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN ONT. ELECTRICAL INSPECTOR UNLESS CONSTRUC T _ S Rough Service ............. .. ........... ......................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. °E �10RTy 7 TOWN OF NORTH ANDOVER 3? biOFFICE OF A BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 ��'•,,.o�••'`cy North Andover, Massachusetts 01845 SSAGH►15�� Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: 9 IL4115 JOB LOCATION: 204, VVAVERL`! TZc_), Number Street Address Map/Lot HOMEOWNERT� ac _4 5 £ 84micim A �AgcvTrff 97f— 6,fl- Name Home Phone Work Phone PRESENT MAILING ADDRESS-2-0(,, t. i)VERLY lZb No A+.tawtpe MA U f F ys City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as su ervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I IO.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and-that-he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 e i t JacksonProSales O rd e r Dealer of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd [_203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber$Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UM I I PricelUnit Extension 1 SOSCHROCK 1 SCHROCK,MAPLE,FLETCHER DOOR EA 94.12 94.12 COCONUT FINISH APC PERIMETER WEP1236F1.5WD 1 SOSCHROCK Due on PO#456809DB 9/2 015 E timated 2 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 202.64 202.64 CONTO W3018 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 3 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 226.02 226.02 CONTD W1536R FB 1 SOSCHROCK Due on PO#456809DB 9/2f t2015 E timated 4 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 21.18 21.18 CONTD F336 1 SOSCHROCK Due on PO#456809DB 9/21,t2015 E timated 5 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA266.93 266.93 CONTD W361824 1 SOSCHROCK Due on PO#456809DB 9/2 015 E timated 6 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 364.06 364.06 CONTD W3636 1 SOSCHROCK Due on PO#4%809DB 912r,12016 E timated Amount: 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00 U Customer agrees that any amount not paid within 30 days of U Total: 10,989.24 invoice date will carry interest at the rate of 1.5% per month Paid: 10,989.24 and further agrees to a all costs incurred in collection Due: 0.00 4 pay , Page 1 of 7 9/4/2015 8:57:34AM Jackson of t Pr es O rd e r Dealer of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence, Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Data Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Tenns Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description uml Price/Unit Extension 7 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 365.06 365.06 CONTD VVMC1236L 1 SOSCHROCK Due on PO#456809DB 9/2 2015E timated 8 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 23.40 23.40 CONTD OL336 1 SOSCHROCK Due on PO#456809DB 9/2 015E timated 9 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 364.06 364.06 CONTD M636 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 10 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 387.79 387.79 CONTD W3636 FB 1 SOSCHROCK Due on PO#456809DB 9/2,1/2016 E timated 11 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 414.92 414.92 CONTD DW362424SR FB 1 SOSCHROCK Due on PO#456809DB 9/2,,1/2015 Etimated 12 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 241.73 241.73 CONTD TEP2490F1.5FPE 1 SOSCHROCK Due on PO#456809DB 9/2 015Estimated Amount: 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* Customer agrees that any amount not paid within 30 days of 00 Total: 10,989.24* invoice date will carry interest at the rate of 1.5% per month Paid: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 2 of 7 9/4/2015 8:57:34AM JacksonProSales Order LUMBER & MILLWORK Dealer of the Year 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd r 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)388-0366 r 09/16/2015 Billing Fax:978-687-5841Location RAYMOND 77777-1 MAIL TO: Jackson Lumber&Milhvork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# I Order Date Oper Purchase Order Terms Ship Vla 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UMI Pricelunit Extension 13 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 1,074.09 1074.09 CONTD U249012 AUTHL rrKP/RECTKL 1 SOSCHROCK Due on PO#456809DB 9/2 015 E timated 14 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 1,074.09 1074.09 CONTD U249012 AUTHR/TKP/RECTKR 1 SOSCHROCK Due on PO#466809DB 9/2,1:/2015 E timated 15 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 414.63 414.63 CONTD B36 RD12 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated 16 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 750.89 750.89 CONTD SLS33R 1 SOSCHROCK Due on PO#456809DB 9/2,1:12015 Etimated 17 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 450.47 450.47 CONTD 3DB21 1 SOSCHROCK Due on PO#456809DB 912f 12015E timated 18 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 286.37 286.37 CONTO TD15R 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated Amount: 10,989.24 Special order and manufactured merchandise is son-returnable. V Tax: 0.00* Customer agrees that any amount not paid within 30 days of U Total: 10,989.24 j invoice date will carry interest at the rate of 1.5% per month Paid: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 3 of 7 9/4/2015 8:57:34AM ProSales JacksonQ Order Dealer of the Year LUMBER & MILLWORK 2014 Transaction_# 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Data Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 r 09/16/2015 Billing Fax:978.687-5841Location RAYMOND MAIL TO: Jackson Lumber A Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description U11011 Price/Unit Extension 19 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 542.70 542.70 CONTD B27 AUTHL 1 SOSCHROCK Due on PO#456809DB 9/2,,1/2015 E timated 20 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 501.04 501.04 CONTD BWB18 1 SOSCHROCK Due on PO#456809DB 9/2 2015Estimated 21 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 372.78 372.78 CONTD SB30ST 1 SOSCHROCK Due on PO#456809DB 9/2 015 Estimated 22 SOSCHROCK 6 SCHROCK FLETCHER COCONUT EA 67.33 403.98 CONTD TF396FH 6 SOSCHROCK Due on PO#456809DB 9/2 015 E timated 23 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 35.22 35.22 CONTD PAINTQUART 1 SOSCHROCK Due on PO#456809DB 9/2,1/2015 E timated 24 SOSCHROCK 3 SCHROCK FLETCHER COCONUT EA 17.64 52.92 CONTI) SSM8 3 SOSCHROCK Due on PO#456809DB 9/2 015E timated Amount 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* Customer agrees that any amount not paid within 30 days of U Total: 10,989.24* invoice date will carry interest at the rate of 1.5% per month Paid: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 4 of 7 9/4/2015 8:57:34AM I I JacksonPreSales O rd e r Dealer of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd �— 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber A Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 �`DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME "EMPLOYEE" " EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Data Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description UM PriceJUnIt Extension 25 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 9.62 9.62 CONTD TKC 1 SOSCHROCK Due on PO#456809DB 9/2f 12015 E timated 26 SOSCHROCK 1 SCHROCK FLETCHER COCONUT EA 24.05 24.05 TUK 1 SOSCHROCK Due on PO#456809DB 9/2 015E timated 27 SOSCHROCK 4 SCHROCK FLETCHER COCONUT EA 34.31 137.24 CONTD VFR8 4 SOSCHROCK Due on PO#456809DB 9/2 /2015 E timated 28 SOSCHROCK 3 SCHROCK FLETCHER COCONUT EA 35.28 105.84 CONTD TB8WD14 3 SOSCHROCK Due on PO#456809DB 912r,r2015 E timated 29 SOSCHROCK 2 SCHROCK FLETCHER CHERRY EA 71.29 142.58 TUNDRA FINISH ISLAND APC BBM8 2 SOSCHROCK Due on PO#456809DB 9/2 015E timated 30 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA EA 545.17 545.17 CONTD VB333418 AUTHL 1 SOSCHROCK Due on PO#456809DB 9/2 2015 E timated Amount: 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* U Customer agrees that any amount not paid within 30 days of T 10,989.24* invoice date will carry interest at the rate of 1.5% per month Paaidid:: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 5 of 7 9/4/2015 8:57:34AM 1 Jackson Pr° the Order Dealer of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd (� 203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# Order# Order Date Oper Purchase Order Terms Ship Via 1810 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# Item Number Ordered Description uml Pricelunit Extension 31 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA E4 185.79 185.79 CONTD BP9634.5CSGR 1 SOSCHROCK Due on PO#456809DB 9/2 015 E timated 32 SOSCHROCK 4 SCHROCK FLETCHER TUNDRA E4 72.72 290.88 CONTD W1530"DOOR ONLY" 4 SOSCHROCK Due on PO#456809DB 912 2015 E timated 33 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA E4 545.17 545.17 CONTD VB333418 AUTHR 1 SOSCHROCK Due on PO#456809DB 912 015 E timated 34 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA E4 19.76 19.76 CONTD OCMB 1 SOSCHROCK Due on PO#456809DB 9/2,1:/2015 E timated 35 SOSCHROCK 1 SCHROCK FLETCHER TUNDRA E4 24.05 24.05 CONTD TUK 1 SOSCHROCK Due on PO#456809DB 9/2f f2015 E timated 36 SOWILSONART 16 WILSONART HARDWARE E4 1.75 28,00 BP53019-G10 PULLS 16 SOWILSONART Due on PO#456809DB 9 25/2011 Estimated 37 SOWILSONART 34 WILSONART HARDWARE E4 0.00 0.00 AK-BP 53005-G10 KNOBS INCLUDED IN PRICING Amount: 10,989.24 Special order and manufactured merchandise is non-returnable. Tax: 0.00* V Total: 10,989.24* Customer agrees that any amount not paid within 30 days of U invoice date will carry interest at the rate of 1.5% per month Paid: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 6 of 7 9/4/2015 8:57:34AM Jackson ProSa'es 4 rd e r Dealer of the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd F203840 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913 Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 F 09/16/2015 Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber&Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer# I Order# Order Date Oper Purchase Order Terms Ship Via 1810 1 203840 08/15/2015 139 EMPLOYEE DELIVERY LN# item Number Ordered Description ptio UMI PricelUnit Extension 34 SOWILSONART Due on PO#456809DB 9 25/201 Estimated s i Amount: 10,989.24 Speoial order and manufactured merchandise is non-returnable. 0 Tax: 0.00* Customer agrees that any amount not paid within 30 days of U Total: 10,989.24* invoice date will carry interest at the rate of 1.5% per month *Paid: 10,989.24 and further agrees to pay all costs incurred in collection, Due: 0.00 Page 7 of 7 9/4/2015 8:57:34AM .Jackson Proes O rd e r Dealer off the Year LUMBER & MILLWORK 2014 Transaction # 215 Market Street 10 Industrial Drive 67 Haverhill Rd 203844 Lawrence,MA 01843 Raymond,NH 03077 Amesbury,MA 01913Ship Date Phone: (978)686-4141 Phone: (603)895-5151 Phone: (978)-388-0366 10/09/2015 —� Billing Fax:978-687-5841 Location RAYMOND MAIL TO: Jackson Lumber 8r Millwork Co.Inc. Sales Representative PO Box 449, Lawrence,MA 01842 �' DARLENE BENOIT Bill To: Ship To: PATRICIA A.MARCOTTE SAME *EMPLOYEE* *EMPLOYEE* 206 WAVERLY RD 206 WAVERLY RD (978)681-9113 NORTH ANDOVER, MA 01845 N ANDOVER, MA 018453532 Customer to I Order# I Order Date Oper Purchase Order Terms Ship Via 1810 1 203844 08/1512015 1 139 1 EMPLOYEE DIR SHIP LN# Item Number Ordered Description UM Price/Unit Extension 1 SOGRANITE 1 STONE CREATIONS CAMBRIA COLOR E4 2,450.00 2450.00 TBD EITHER SUTTON OR WINDEMERE NO BACKSPLASH PERIMETER,STAND ARD EDGE EITHER PENCIL OR BEVEL 1 SOGRANITE Due on PO#456817DB 10/16 2015E imated 2 SOGRANITE 1 STONE CREATIONS CAMBRIA COLOR EA 1,996.00 1996.00 TBD EITHER SUTTON OR WINDEMERE STD EDGE,ISLAND COUNTERTOP 1 SOGRANITE Due on PO#456817DB 10/16 2015E imated Amount: 4,446.00 Special order and manufactured merchandise is non-returnable. Tax: 0.00* C) Total: 4,446.00* Customer agrees that any amount not paid within 30 days of U paid' 4,446.00 invoice date will carry interest at the rate of 1.5% per month and further agrees to pay all costs incurred in collection, Due: 0.00 Page 1 of 1 9/4/2015 8:56:31AM 248"- -27, 7B„ FZ1 R, m N WEP1231 W3018LO 1536 , N W361824 N 3D621 � L' TDI 5R 9 H ANGE GfS 30- )W - -------------- TEP2487F1.5FPE Schrock,All Plywood Construction m� r� MUJ C l with Full Extension Soft Closing Drawers k and Doors, Perimeter and Pantry wall is wo Fletcher, Maple, Painted Coconut, Island is Fletcher, Cherry, Tundra , Finish co ' C7 tr 0 , $10,655 O 30 cMol ro O O m O s u Q2 M O m �, O m w t o rn Col � Co 11 #4� t~�. All dimensions size designations DARLENE BENOIT This is an original design and must Designed:7/25/2015 given are subject to verification on JACKSON not be released or copied unless Printed: 8/7/2015 job site and adjustment to fit job LUMBER applicable fee has been paid or job conditions. -MILLWORK order placed. Marcotte,Patti-Tom Island Schrock All Drawing#: 1 I No Scale. a s . r 6= a t Eq If I if s , Ro. . ir xi r.t. iti �� The Commonwealth of Massachusee`ts Department of IndlustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02.114-2017 www mass.go-v/dia sy. Workers'Compensation Insurance Affidavit:Builders/Contractors/Elgetricians/Plumbers. TO BE MED WITHTHE PERIVIITTING AUTHORITY. A131ilicantInformation Please Print LeR bly Name(Business/organizatioWkdividual): h-{0"A S - MARC 0 TE Address: Z06, WAV LY --- City/tate/Zip: A�0. �10t�►/� 01 15 Phone#: 7?- of 7-5/113 Are you an employer?Check the appropriate box: Type of project Orgquh'ed): 1.❑I am a employer with employees(full and/or part time).'` 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in &. K4 Remodeling any capacity.[No workers'comp.insurance required] 9. El Demolition 3.0 T am a homeowner doing all work myseLf.[No workers'comp.insurance required.]t 10 []Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. Twill ensure that all contractors either have workers'compensation insurance or are sole ILEJ Electrical repairs or additions proprietors with no employees. 12.. Plumbing repairs or additions 5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurances 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[�Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing theirworkers'compensation policy information. 7 Homeowners who submif tlris affidavit indicating they are doing all work andthen 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 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 ioviding workerscompensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or S elf-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'cbmpensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a eximinal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under°thepains an penalties ofperjury that the information provided alcove i true and•correct: signature: Date: y V Phone#: Official use only. Do not write in this area,to he completed by city or town official.. City or Town: PermitMeense# 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#: s 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 lire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,of any two or more of the foregoing engaged in a joint enferprise,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 ofthe 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=contractors)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 maybe submitted to the Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the afCzdavit. 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 rcqufred to obtain a workers' compensatimi policy,please call the Department at the number listed below. Self-insured companies should'enter their• self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill.in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia