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HomeMy WebLinkAboutBuilding Permit #513 - 30 MOUNT VERNON STREET 2/16/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 5,13 Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNER a rf �. Print Print MAP NO: `kQiPARCEL: ZONING DISTRICT:_; [ Historic District yes Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Septic Well Floodplain Wetlands Watershed District _ Water/Sewer ur-O ,/rar 1IVN ur VVUMM I U 1St PERFORMED: IL / Sin s �w I l .e p lc �r e,�Y- l 44d'ec 24 Gn J G''H�e � ..✓ � ,�rii by 1&_,,,w ji"�+ A _T1e wt, A e I.-Al5e /�leGlL� Please OWNER: Name: Address: Print Clearly) Phone: I Y V At,) z 'CONTRACTOR Name:r ciiw 5�6s I& Phone: Address. 2-,f g ,, /A, Supervisor's Construction License:9 d 9 Exp. Date: // 111201.0 Home Improvement License: Ilay 8 9 3 Exp. Date: 111310 12011 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $-3'-7(.o94 FEE: $ Check No.: Z_ Receipt No.: NOTE: Persons contractin*49k unregistered contractors do not have access to theamy fund �ignature of Agent/Owne ' ignature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well - Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS i Reviewed on Signature A l /A Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments =Conservation Decision: Comments 4Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 USgood Street FIRE DEPARTMENT Temp Dumpster on site yes no Located at 124 Main Street Fire Department s gnature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. _Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check. Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be -Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe: Doc.Building Permit Revised 2008 Location,3Z) n'1"?` V6t-N91''1 No. Date — �o lv LO*Th TOWN OF NORTH ANDOVER ` A Certificate of Occupancy $ s'—.ree. ' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # 142, 22bUI V4_1��� Building Inspector . Feb 3 2010 9;11AM No. 0260 P. 11 ClientA)��Y Loose WOOF or FIG 2.2 CaN dose M Q N iO0 ✓ G /� FIG. or Wbol belts s 2 Vbnnkullte 2.9 Attic Vents Type Size Location Amount Present �- E Needed Insulation Existing R R Added Square Feet Notes unfloorw Flowed Slopes Kneewalls Kneewall Floor Flat Roof Hatches NAU.kAy Weatheistrip and Bait Cut And Close Attic Walk u -Dome Cut and Finish Knob & Tube Yes No Storage to move Yes No Recessed Lights Cheeks Feb. 1 2010 9:11AM 2 a a No. 0260 P. 12 b s a 0 Feb. 3. 2010 9:11AM No. 0260 P. 13 Attic Inspection Form Mandatory for all Attic insulation Jobs Client Name CrftL TJZ,f Job # 3 �� � — Date a. Section A: I To be filled out by WAP auditor during Initial interview wM client Are thele any recessed lights in this dwelling ? YES NO Dont Know Locations: Section B: I To be filled out by auditor 1 Recessed Ughting Fixtures P inspection of the ceiling area beneath the attic Other potential Heat producers C ► gA ou.T Section C: To be completed by the Insulation contractor at the time of imleAatlon. Number of recessed lights Fumace !lues Should agree wldt Other heat Producers Section B: Tota/ Guards needed Section D: To be s/gned by insulation contractor after compleflon I have Installed guards Contractor Doe: signed Section E L To be signed by the weetheriaation cff" i agree that the number of insulation guards indicated have been installed as noted above. I have received the notice to the clibm that was attached below Signature: Dare: •-----------------------------•---------------------- --------------------- Detach here and give to Client Notice to Weatherization clients: The purpose of the insulation guards is to ensure that your dwo ing Is in compliance with the National Electric code .Tire insulation used meets all Federal test spefieations. Howeversinee insulaflon nrtains heat, it is essential Mat heat producing sources be protected. For this reason it is Important that the insulation guards not be removed altered or covered. Be sure to use Insulation guards if you install new recessed fight fixtures or some similar fixture. Also be certain not to obstruct any attic ventilation devices. Feb 1 2010 9:12AM G.L.C.A.C,, INC. 350 ESSEX STREET LAWRENCE, INA 01840 WEATHERIZATION ASSISTANCE PROGRAM WORK PERMIT - No. 0260 P. 14 certify that I am the owner/ authorized agent for the property at: Ht V ;n -njr) Srij l MA (Address) 1 further. certify that f have given my permisslon to allow work on .the . prope isted above in accordance with the following provisions: '1. WEATHERIZATION Z. HEATING SYSTEM WORK 3. 4. and such oth culars as may be •attached to this agreement. SIGNED: - DATE: OFN&AUTHORIZ0 AGENT DECEIVED 14AR 10 2009 n Feb. 3. 2010 9:11AM No. 0260 P. 6 Greater Lawrence Community Action Auditor. Bill Watkevitch Phone: 978-857--7871 Job # 3 L/y q App# a-ooq o) 2�2 - -- Date: Client First.: r 1 Last: ` Address:. AJ 9fty Alo-Ald6a D Code C Phone lstflr third fir Phone 2 - House Type., Cape Ranch Split 1 fam 2 fam 3 fam du lex other Victorian Colonialenemen - Siding Type: Wood in A/umn Asb Single Asb Dble Condition (�jp Fair Poor Vin loverAsb T111 Brick/Stucco Asphalt Comments. Roof Type Roof Material Gab! Hip Bkt Gambmi Asphalt tate Rubber Tar & Gravel Condrbon G Fair Poor Heating System BACHARRACH, INC. E fficlency FYRI T E PRO ANALVER Manufacturer : Excess Air Stack Temp ----------------------- __ ...... FHW Sf�eam FHA Space Heater Prima T®m DATE: V21/410 Oil Gas Electric Oxygen TIME: 1203 PM Wood Pellet Coal CO 2 FUEL (F2)Oil 02 CO Pipes Insulated: Yes No CO Air Free. EFFICIENCY 83.3 X Treated Ducts: Yes No Draft EXCESS AIR STACK TEMP 40.0 x 440 IF Flame Color PRIMARY TEMP 46.6 IF Domestic Hot Water Tank Excess Air DELTA TEMP ---- ° F o2 6.3 X Gas Oil Electric Tank less Age CO2 10.9 X Gallons Temp Seung Ambient CO Co CO AIR FREE 13 PPM f 19 ppm Amb CO: Stack CO: Date refend Add 6 Feet of pipe wrap YES / NO Referred to WA Draft 0.04 WC Comments. Smoke Reading cn+mws:. _._.. . Ambient CO Readings : Stove Qa Oven 0 o Broiler OD Dryer_ F b 1 2010 9 11 AM client .30 MI-v–?I'Uu—,ti –ST aoxy NO A000veg Doors No, 0260 P. 7 Location K& Aub Reg Caulk Caulk Repaif—s. Draps Comments Sweep IN OUT Fmnt to out Front to Hall Rear to out Rear to hall To affic To Basement Basement to out other other other Location Condffibn Fire place LJV)A& QDDA Cam Damper&No Space Heaters Blower Door Pre Post Reason not doing ud Knob and Tube Yes(V DO Locavons' Date inspector called Blower DoorAIr Sealing ,Feb 1 2010 9:10AM asure WORKORDER 9 1. WEATHERSTRIPPINGICAULKING �"��LcitIiT` Door Sweeps (Regular) )' Reglaze Windows M.inch Window.Weathstr Schlegal per side A Attic sealing with 2 -part foam man/hr SUBTOTALS 2A.1 NFILTRAT IONII NSULATI ON Domestic pipe Hot Water Tank 1st e' Sill Insulation R-19 CF Drape Perimeter R-5 Anch. Sq. ft. Drape DOOR R-5 Anch, Tape Joints (Aluma Grip only) per hr. Dud Insulation & Tape Sq.ft. Rigid Foam Board Anch.. Hydronic pipe insulation to 1" R-5 Hydronic pipe ins. 1,25%1.5" R-5 Steampipe Ins. to1.25" iron pipe R-5 Steampipe Ins. 1.5"- 2" iron pipe R-5 Air Conditioner Meeting Rail Air Conditioner Cover SUBTOTALS 2B. INSULATION Open Unrestricted R 49 Open Unrestricted R 38 Open Unrestricted R 30 Open Unrestricted R 20 Open Unrestricted R 10 Restrict FL/Sloped R 30 Restrict FUSloped R 20 Restrict FL/Sloped R 10 R-19 FGB open raRers/walls/kneewalls R-11 FGB open raRerstwalls/kneewalls Attic Stalrs(stairwell & common wall) i(�iQ�Cet* � ..:. • .- 'ti8�f�tWlre: Site bulk pull down stairs x foam box W.S_ & bat Hatch R-19 /Q -Lon or = No. 0260 P. 2 3449 GeS�'an�+atr"°�t'�pte�c�°�' Client A3 - " , AW: d0ver QUANTITY r:. ; .;:.' 849 TOTAL 1/29/2010 61 0 iT-- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 04 0 0 At 0.00 K IMM - 0.00 0.00 0.00 13TS0 0.00 287.75 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -IM-Mr 0.00 0.00 . V. J. LVIV 7. I Inm 0 IVU. VLVV I. j Vents Gable rectangular 0 0.00 Kneewall R-12 cell behind Per.Memb 0 0.00 Open Rafter R-20 Cell. AN poly 0 0.00 Basement Overhead R-19 fiberglass 0 0.00 Basement Overhead R-30 fiberglass 0 0.00 Crawlpace Overhead < 4' high R19 0 0.00 Garage Ceiling cavity filled w/ cellulose 0 0.00 Vent Soffit Rectangular :1211Sn'A, NIXKZ:46i� Wood,Shake,Clapboard,Shingles Vinyl 2-hole 0 0.00 Asbestos (single nail) / Asphalt dense 0 0.00 Asbestos (single nail) / Asphaft 2-hole 0 0.00 Asbestos (doub. Nail) / Aluminum dense 0 0.00 Asbestos (doub. Nail) / Aluminum 2-hole 0 0.00 Brick/Stucco dense 0 0.00 Brick/Stucco 2-hole 0 0.00 Vinyl over Asbestos 0 0.00 Multi-layered 3 or more layers 0 0.00 Drill rough plaster or finish wood plug dense 0 0.00 Drill rough plaster or finish wood plug 2-hole 0 0.00 Drill finish plaster dense 0 0.00 Drill finish plaster 2-hole 0 0.00 Test Drill Walls (all 4) 0 0.00 SUBTOTALS 1842.24 2. INSULATION TOTAL 2A.+2B. 1842.24 3. STORM WINDOWS/DEADLITES Plexiglass up to 88 W. 0 0.00 Additional per UI over 8611 0 0.00 Glass up to 88 u.l. 0 0.00 Additional per Ul over 88" 0 0.00 SUBTOTALS 0.00 5. OTHER MATERIAL Ridge vent In ft. 0 0.00 Vents Gable rectangular 0 0.00 Varipitch Vent 0 OAO Wooden Window vent custom to 42 0. 0 0.00 Additional over 42 u.i. for vent per u.i. 0 0.00 Vent Roof #865 Small 0 0.00 Vent Roof #135 Large 0 0.00 Vent Soffit Round 0 0.00 Vent Soffit Rectangular 0 0.00 Turbine Vents All 0 0.00 Stack Vent 0 0.00 PROPA VENT 0 0.00 Fzb. 1 2010 9:10 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation. The Work Order must be Complete within 10 working days from acceptance date below: CONTRACTOR/COMPANY: ACCEPTANCE: AUTHORIZED SIGNATURE: 6v;5 �' A APPROVAL: AUTHORIZED SIGNATURE: No, 0260 P. 5 DATE: 2 DATE: lql7'6" t) 02/05/2010 FRI 14:50 FAX 6174231789 12002/005 i I A� ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ 5 0 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Paul T. Murphy Insurance Agenc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 Lebanon St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Malden, MA 02148 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Scottsdale Ins Advanced Energy Solutions LLC INSURERB: Peerless Ins 75 Greenwood Ave INSURER C: AIG Wakefield, MA 01880 INSURERO COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN3 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 THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. INSRAte' TV'Pr.OF INSURANCE POLICY NUMBER POUCY EFFECTIVE POUCY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 D LED MI G T' FaRENTo rrence $ 100,000 A X COMMERCIAL GENERAL LIABILITY CPS1014919 5/7/09 5/7/10 CLAIMS MADE Fx_1 OCCUR MED EXP (Anyone person) $ 5 000 PERSONAL& ADV INJURY S 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - OOMPIOPAGG S 2,000,000 POLICY PRO LOC AUTOMOBILE LIAOUTY COMB WED SINGLE LIMIT $ 1,000,000 ANY AUTO (Ea accident) B ALL OWNED AUTOS 8633314 3/19/09 3/19/10 BODILYINJURY $ X SCHEDULEDAUTOS (Per person) BODILY INJURY $ X HIREDAUTOS X N ON 40 WNE 0 AUTOS (Peraccideru) PROPERTY DAMAGE $ (Peracciderd) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANYAUTO AUTO ONLY: AGG $ EXCESS I UM BRELLA LIABILITY EACH OCCURRENCE $ _ AGGREGATE $ OCCUR CLAIMS MADE DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STAT OTH- AND EMPLOYERS' LIABILITY YIN EL.EACH CODENT $ 500,0 0 ANY PROPRIEMRIPARTNERIEXECUTIVE 006789459 5/14/09 5/14/10 C OFFICERMIEMBER EXCLUDED?Ni (MandalDry in NH) EL_ OIS SE -EA EMPLOYEE $ 500,000 If yes, describe under SPECIAL PROVIS IONS below EL. DIS ISE -POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Blown & rolled Insulation - Coverage is subject to policy terms conditions and exclusions. Disclaimer attached. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Gail Tahzer NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 30 Mt Vernon St IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR North Andover, MA 01845 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE I ACORD 25 (2009101) © 1988-2009 A D CORP ION. All rights reserved. The ACORD name and logo are registered marks of ACORD e �a The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: �2 9 /,h a Ci zS L:-L,G Phone #: 7V — 41 7s < Are you an employer? Check the appropriate box: 1.0 I am a employer with 4. ❑ I am a general contractor and I employees (f,11 and/or part-time).* have hired the sub -contractors !. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] S. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. These sub -contractors have employees and 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 11.❑ 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 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: 7 Policy # or Self -ins. Lic. #: 06 (0 % ( Expiration Date: 5� 1 ! Job Site Address: 4 MT 0e-v-&loi.^64- City/State/Zip: ��. �-�, �..�fOy�v, I f q oaq - 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 under the pains and penalties ofperjury that the information provided above is true and correct. C✓. Phone 4/- Y7,�_- 2,!:)%S 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 M 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-477-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia f ✓1ze �amimaouvea/.C�i o���aQa�re�ivaeda A�' Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR, Registratio X64893 Expiration ���W12011 Tr# 291184 1 Type £oc oratii9n , j ADVANCED ENERG 3 T- S LLC. I RICHARD BOR ; 28 HAMILTON RD`. PEABODY, MA 019606 `= Undersecretary- . 9 - Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 90902 Restrictedto: 00" RICHARD B BORGES 54 ECHO STREET . . MALDEN, MA 02148 r h c— �"'�" —� Expiration: 11/1/2010 ('uctill] i.sivner Tr#: 14002 6 W W R. �¢ x w A 0 Po z z o x w aa U _ o w w w Im w° Z Z v� a o w° ao' U w a b a°' coW w U a co w C7 U ao' w w x a as d z cn v cn • � o m c ` C h _O C ' a'O o C=c 2: 40i ® C _ 4r N a 0.9 _C z N EC O ,00 Scm �o y'O �: 4 m m a CD N as m � N F-1 E m W -" ,. m O o.L) m N m 4:D. CC cm N •� W 3mo m ccc H Z o O.— CD : +rC d O C O O m C C = O0� p N $ 06 N m $ ~ m Nd= O C Z uj � O r O •N C) V .m O ®:C c H d O 'O O :SCA mo cm O L O Z � O y D C I C C CO)CO2 -0 co O C '9 m m CL co CD o CD0 ci cc o a a. cm< CO) C o � � O 12 'fl C. -O CD CZCD CL V ND O C O CO2 ca W 0 LLI U) V9 W LU U) 1 eb. 1 2010 9;10AM IMM No. 0260 P. 1 Greater Lawrence Community Action Council, Inc. Hwap / Wap Program Fax �IL _ � To: Advanced Emergy Fax: 978-587-2596 From: 1801 New #978-857-7871 Dab: 2/3/10 30 Mt Vernon St No paqw. Andover CC: Richard ❑ urgent 0 For PA*W 0 pwm camnw* ❑ ft* ❑ Flue Recycle Comments: NEED TO PULL CITY PERMIT New Job#3449 Gail Tamer 978-258-1649 S "j, s � -� l. aft ESSEX STREET LAWRENCE, ■A r'1l97-Bi1-4555 OR 978-611-4956 147, •'� - ■E■MI.... ■E■ MEN Feb. 1 2010 9:11AM Client 30 hrryt2,2n2 1*11)0(.e v N o . AVC ovc2. Basement Conditioned Uncondidoned Asbestos Yes (DO Location Basement Overhead Garage Overhead Sills Drape perimeter Crawl Space I Done Steam Iron 1!2 inch 3/4 inch 1 inch 1114 inch 1/1/2 Inch 2 inch Done Yes No Measurments No. 0260 P. 9 Crawl space Dirt floor Added R SQ Feet Pipes steam i Duch Basement Mastic seams Square footage hrs Basement Door Drape Repair Caulk Kit & Sweep Feb. 1 2010 9:11AM Client 30 /n7 VC9 A/O A/ S7 No. 0260 P. 10 No A AviOvVC1I, walls Floor Plan x vA z Commelt3 y 90 �l / Exterior well fa: 26 X =64 Exterior wall nu ] 6 X =60Y Interior wall X ist Loa KA TO AW 2nd 3rd Sq Feet iv Ifo Common Ad" Total Pjame indicate: unheated /I///// Common