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HomeMy WebLinkAboutBuilding Permit #738-2017 - 328 MAIN STREET 1/26/2017TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1 l permit N0: ;-0/ 7 Date Received &L Date Issued: IMPORTANT: Applicant must complete all items on this6page NO.j am � ' �[PARCEL:� ZOO I p c 'c i Structured yesno ,y �tnct UY.es o , tno u c OWNER: Name: Identification Please Type or Print Clearly) k J�eti(A ARCHITECT/ENGINE ER Phone: '� Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ Ll FEE: $7. Check No.: �6 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ..gnar er ". ; e: of:.con. ractor :. iu 6of.A Plans tu= : Submitted ❑ Plans Waived ❑ Certified` Plot Plan ❑ Stamped Plans ❑ I- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE:OF .SEWERA,GE DISPOSAL Public Sewer ❑ Well ❑ Private (septic tank, etc. ❑ Tanning/Massage/Body Art Tobacco Sales Permanent Dumpster on Site El... Swimming Pools ❑ ❑ Food Packaging/Sales ❑ 1-1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORMA DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planrfing Board Decision: Comments C, Conservation Decisi Com Water & Sower Connection's ignature � Date Driveway Permit DPW To-vvn ]Engineer: Signature: FIREDEPARTMENT - Temp Dumpster on site yes Located-at'124 Main' Street Fire DeO!imerit signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories: Total square fleet 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 2010 FO- Building Department True fol stwing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofiiag, 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 MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products DOTE: 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 o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products TOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cE-iscs. if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the; apn,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be- submAted with the building application Doc: Doc.Buhding Permit Revised 2012 Location rN S l No. �i ! ` Cl al I Date otolkbl-7 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit -Fee Foundation Permit Fee $ Other Permit Fee1-1 TOTAL $ -�- / Check # 31474 1// Building Inspector v C � N 0 -0 O CD CD O -0 �• N -a O � <v� CL C S CD CD o c� CD C v CL 0 U� U) � v 0 U) z CD 0 0 e� o CDO CD c� co 0 Z . cn a O z m cn O C 0 z m X -v cn z O cn O D 0 z O 5 CD N R (O O W O CD cc 0 N 0 a: N N M CD O O cn rD __ " O w O Oq N =' < CD 13 cn CD0 CD 0 0 = C W m 0 rn m n n 3 T c 3 0 O o = -0 U) T O Q S O N „O, f FD -TI N Oona 0 m cn Co n1 O N O —i = O C CD = -z CD O C n —I (Q Q. O rr N• O O _�CD :® CD - = :e o � O 0 o N -� cn � CD :e V off, h Cr '.� _ S. �D n D � n � co Toll0 N 1i1 < CL CD O CD N cD CL rL 10 CD N 0 '= o c 0 rt OCD O CD lD N 0 - DCD O a) O CL t v In 3 O rD cn rD WT C O T O vH m Z O w O Oq H n O x T 3 N O < 77 O cm zTO_ rm A Dr H m 0 _TI 3 w O 04 C W m 0 T O n S 3 Sa O DO T c 3 0 O C G Z O cn n O x N o '"�. n Ln 3rn T O Q S W O x x O 01 "" LJ El---, JS3 Federal ID # 05-=5629 RISE Engineering R1 Contractor Registration No 8186 MA Contractor Registration No 120979 1� 11�f CT Contractor Registration No620120 f RISEGel Shacwmnt Road. Canton -MA 02021 p �� ENGINEERING' CONTRACT ���TRA 24 339-592433-5-�339-592433-5FAX 339-ip-f�3 Page i PROGRAlNI THIS COYTRAC T IS EIITEREO VITO DEW EEN R65E CMA -I1 ES EUWSE£RRIG A"rD THECUSTOM FOR WORtt AS nEscRieIDREwn CUSTOMER FROnE DATE Gi=rt' ■ WORK ORDER Eugene Belivcau (978)8284393 01/1712017 443643 SERVICE STREET _ .� _ 19RLtpG STREET l.. _ J ,• , "-'�. _233902 `.4( .r 328 Main Street 328 Main Street -. .- SERVICE CITY, STATE, ZIP SR.t=G CITY. STATE, 7tH North Andover. MA 01845 North Andover, MA 01845 LO 17 � 1 JOB DESCRIPTION HAZARD BARRIER: We have identified that there are recessed lights present in your home. Unless the recessed tights arc certified as iC-rated (Insulation Contact Rated) lire will create a T clearance space around the fixture by using fiberglass blanket insulation as a damming material. no insulation will he installed across the sola and closed cavities which contain reeessed lights will not be insulated. S1f.0(1 Alli SEALiNG: Provide labor and materials it) scal area: elf your Wait acainst waslcful. excess air leakase. 111is work will lk: performed in concert with the use Cf spcuial tools :Ind diag-Exi5tic test% to assure that your home will he lett with a licatthful h. -VVI irf air c%chansc and indmir air quality. Materials to he used to seal Your home can include caulks. foams and other products. Primary arras fnr Seal Ing include air ieaka=c to attics. hiewinems. attached garL es and other unheated areas twvindow a are not=cTicrall} addressed.) This will require (11) working hours. A reduction in cubic fret per minute (cfm) of air infihrmion will occur. but the actual number of cfm is not gamantecd. At (he completion of the mmtheri72tion work. and at no additional cost to the homeowner. a final blower door andfor combustion safety analysis will be conducted by the sub -contractor to ensure the safety of the indoor air quality. 5935.00 DAMMING: Provide labor and mahcriab to install a 12" layer of R-38 unlaced fiberglass baits to (80) square feel for damming purposes. SI (x1.00 A t-f1C FLAT: Provide labor and materials to install a 9" layer of R-33 Class I Cellulose added to (1123! square icei of open attic Space. $1.694.50 NITIC SLOPE OK - Ola - SLOPES 50.00 WI 1011HOUSE FAN: Provide labor mid materials Hl fabricate and install a rigid loam insulating eoer for the, whole house: No. $209.21 A'rl iC ACCESS: Provide labor and materials to install (1) CaCily moved. insulating covcr for the attic accC55 folding Siair. A small flat surface of plywrxid will be created around the opening within the attic. This uill allow the cover', inteeral weather- stripping to restrict sir leaf age. S237.63 VENTILATION: Provide labor and materials to install (1) insulated exhaust hose In existing bathroom fan(s), S60.00 VENTILATION: Provide labor and materials to install ventilation chutes in (36) rafter bats to maintain air flow. 590.00 COM'NION WALES: Provide labor and nraterink to instill R-13 unfeed fiberglass to 130 square feet ofeommon wall. Then Federal ID #05-0805629 RISE Engineering RI Contractor Registration No 8186 o4 )� FAA Contractor Registration No 120479 t, CT Contractor Registration Nio620120 RISE' ENGINEERING' GO Shawmnt Road. Canhm, JlA 02021 CONTRACT 339-502 6335 FA 339-502-6345 Page 2 PROGRAM CMA-11ES W.GGUM-EERRMMWTT ��T wuvroano 'RKAS DESCRMV SUM Pw%l DATE CUEflr it WwK DRDER Eugene Beliveau (978)8284393 01/17/2017 443643 23902 ea.►utG STREET 328 Main Street 328 Main Street Smgce C"Y. STATE, DP _..._ a UAX CITY. STATE, PIP North Andover, MA 01845 North Andover. MA 01845 JOB DE SCRIPTION install rigid board at R-10 or gmater with the required fire rating that meets the seclions R-316.5.1 and 316.6 requircntcrits of building code. Seal all scams with FSK tape. Sf52. ift COMMON % At LS: Pmvids: tabu+, and materials to install ri_id board at R-10 or greater with the required fire ratinLLg, to 4401 square Meet orcomaton E'all area. Sl i01() OVERHANG: Provide labor and materials to install 7" R-25 densely packed Class I Cellulose insulation to t7i J RISE' CUSTOAPER Eu_ene Beliveau SERIACF STRM 325 Main Street Engineering 60 Sbtatvmut Read, Canion-11A ( anion -11A 02021 339-19024.335 FAX 339-502-6345 PROGRAM GAZA -HES (978)8294393 - .SVJ= STREET . 32S Main Street Fe&*rM 0 9 054M056n RI Cantra:torRegistmwn no eiaS ITA Cantractar Reejstratim no 1211979 Cr Contsctar RegW=Uun No620120 Paige 3 THzs Gc�;raRACT 8'n Eiri��j' D ciiq�ilfEfit sass E%�rT...rr�f ir.'+Ti'iGA T1E CiISTOfFER' iOq t`309J5 AS Dom,, DATE MMUTA 1F$=ORDER 01/17/2017 4436,43 23902 SERVICE CTCY.STAIE W on=.- Carr STATF-ZIP -- North Andover. MA 015;35 North Andover_ MA 01545 ,SOB DESCRIPTION RISE Fn_ehiccring Tvill :blurt♦ all applicable. efr_ible inJx, whres to this contract.. You J411 only be billed the Net wriount, Catrerttly- for clieible measures, Colunibia Gats offers 75% incentive. not to exceed 52.001) per c lcrul<tr year, and an incentive of I00EA for the Air Soling, messurcc op to the first 500 and an :additional 5340 if savinas are justifcd by the atrdhor For The safer` and health of wtur home's indoor air yualitv� Tec :rill be Conducting_ a blower door diagnostic orthe available air flow in your harnc beth hefore the ural; is begun, and alter the zceathcri"rrtietl [cors; is complete_ We will also CMWUcl :a full ;issee[ "cit; of the combustion safciv i=f %"Ir tui. tint saricin and uaicr lwater,1'his has a value of S90 and is at no east to _ ou. 'fatal allowabic ucatherization incentive is 53.1117. 1"hc Itcrtiiit will be secured bs the ilrcttlation contractat.:a Jut additional cosi- It L% dict hoummizees wsponslbility to cki.y. Utti ibis permit by contactits_ Alkit ntunic:ip:dity at tin compkiion of this a cY L I � 1 a,` Cull t total: Program Incentive: Customer Total: WE AGREE HEREBY TO FURNISH SERVICES - COMPLETE Ri ACCORDANCE YAM ASOVEE SPECIFTCATiOtrS. FOR THE SUZ OF *'*One Thousand Severs Hundred Two & 041100 Dollars UPOIS FCML HiPECTtO.: Atm APPROVAL BY RISE EUGM EMIG. CUSTOMR AGIIEFS TO REtt3T MIOU.IT DUE RI FUU- MEREST OF 1%TALL HE CHARGED AtOT;nkV ON AUY UWAMBALANCE AFTER 30UAYS. SEE REVERSE FOR U3PORTART WFORMA71014 On OUARAInEES.BIGHTGOFRECIMWl,SCHEOULL.V /SIDCORIRACTOHBEGISTRATRIit. NOT SIGN THIS CONTRACT IF THERE ARE ANY 81-ANK SPACES AUTHDR SeGlIANR -^EE ;i ng/CtCE DOTE: THIS CO^fTRACT MAY BE ATTHDRAW; ST US 1Fr;DT FSECUFED TLTIHUI 30 DAM DATE OF ACCEPTGP/CE 590.00 $4,727.04 $3,0255.00 $'1,702.04 $1,702.04 ACCEPTAL EOF COMRACT. THE ABOVE PRICES. SPECIFICATSOAS ARDCOIRKTKV:S ARE SATSFACTORY TO US AND ARE HEREBY ACCEPTED. YOU ARE AUTHOW10 TO rm THE WORK AS SPECIFIED, PAYMUT VML BE MADE AS OUTUttED ABOVE 60 Slhawmut Road, Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com e- 49a / r 3z (Owner's Name) owner of the property located at: S lam...^........� p......_«.. A � � (Property Address) (Property Address) hereby authorize A B Vv , (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners responsibility to close out this permit by contacting their municipality at the completion of this work. Owner's Signature t Date 62016 �5;. puw�, , of cluilding arld C'""Pl4ct's)" SLPt*r% iz:ense: CSSL-106ID19 Jy. TODD UTWC 95 QUEENS East C-rmawich W ON 0212Wnja C arcoummer Affain MPROVEMEW CONTRACTOR ow 179572 Type.- MemM6 coq*rftn '41-T(?RDABLr= WIWING & VvEA7jjERLAT,0j4 IMC TODD LEfxx 95 QUEEN ST#3 E. r-REr=MVMCK lel M16 tindtc ecac aTY Restricted To-- cssL4C- IrtsulaWn Contraaor i Wureto Pmess a current edition If the Mawsaduse"s State Building Code is cause for revocation of this lkmlse_ %f OPS licensing information visit: www.mm_C .'OvIon L'=W Or M&tr3fi0ft Valid for WdW&l,,L, only b9f0re the exPiT2600 date- If found roure to. Oise of Cd Affairs and B,,im Rgulutign 10 Park PhM3 - Suite 5170 Boston, MA 07.116 Not valid Witbout —skmatur—e—'— Wet -keys' Compensation lammuce Affidavit: Bufflers/Contiractors/Ekvtiidans/Plmbe-rs AM)"Ut information Pleasefrilat LgW_b!j Name (Busineworgantmowbdividual): Addrm: 5*50 City/SlawZip: Phow #- 401 aS. Are yon au emploW. Cbmk Se appropriate boj.- Ty . pe of project (requhvd) 1.1-�Ptdsmaem-ployerwith %C:� 4. 1 am a general contmetor and I 6, El Now construction employees (M andlorpalt-lime).* a sole xietor or partner- 2. [J— I am prq have hired the mb-c�wun I ided on the atta&ed dwzL 7. n RemodeUng ship and have no employees ThAw sifb-=ctors have S. 0 Demolition warkiagg for me in my Capacity. (No wozkm' comp. insunince workcW COMP. insuranoc. We are a corporation and its 9. rl Building addition requirc(L] ffic om have exercised their 10 -El Elechicaj rzpi�n or additions 3. El I am a bomeowner doing all woik nght of exemption per MGL 111-1 Plumbing repairs or additions Myselt [-No wmim' P. c. 152, § 1 (4), and we have no 12.[] Roofrepirs insurance rvlke&l T I emplqyees- [No wmim' comp- instomce required.] 2g Offier 13.JnSUACLtCj�n M==11d9cksbox"fi Mmt also fill M ft wmm bdm coinpwsaw. policy infamumm 1, siAn4thm A idavk ufficamg1hey we doirt all wmk &Id dim ?we (MMXk codracims Mutsulmit a oci-V affithyd Uw1caftE such. 'tCo, ewmft check ftsbm- wwt3uW anaddWom'SIMISIMMgftTAMeGfik M*�aastsae3crrs Ad PWMy MfoMrMarj law an eaq;1Ivyev&W isprorAft warkem' conrcgufivn iwwaNceftrDW eMF4em Below isthe po&g., and joh size Mformfio& JnMrMC--CIDMP-I-UY -Name: Ekaspera_ jAjX:jjjg%j Policy A or Self inf, Lie. E-Vii-vion D&te:— Job Sfte Address: Cir f1stalemp.- Aftach a copy of the workers' cmapensaftan polky dectarat%u page ts0►win the .Polk number and. expautWn date). Failure to seeme coverage as required under Section 25A of ML c- 152 can lead to the impasitkm oftriminal pr-voltics of a fine up to $1,500-00 andlor one -Year RUPY'sUnIne4 as Well as civil MaWeen in !he tom of a STOP WORK ORDER and a fine, of up to MO.00 a day agafit-A the violator. Be advised that a copy oft his statement may be fbrwarded to the Office of InveWw6ow of the DIA for insurance coverage vedf jcation- I do hert under tkepda andpamMes ofpffft" AW the ififVHXUion pMvi*d above is fare and cayred -phope M 9401 - !R 45 - -8 S -7 8 Oj,rtd,d arse ozdy. Do nw 'wrke in A& area, to he comTAMa, by efty or town offidaL City or Town: Permimkense # Issuing Authority (ckcLe one): I. Board of HeAb I BuNding D"riment 3. CiqTmn Clerk 4. Ekcb*al hupector 5. PIMMbinginspectur 6. Other Contact Person: Phone #. ACt./R® CERTIFICATE OF LIABILITY INSU INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS ■ V INCE 4//8/28/201166 THIS CERnFICATE 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: N the certificate holder is an ADDITIONAL INSURED, the poTlcy(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 M . Mieki Vee=man Loiselle insurance Agency 279 Dexter Street PHONE (401)723-8510 (401)'728-1820 E""A8 micki@loiselleinsurance.com P. O. Box 1148 Pawtucket RI 02862-1148 AFFORDING COVERAGE MAIC INS ABMC Insurance INSURED Affordable Building & Weatheriaation, Inc. 77 Pitnam Street Unit 100B providence RI 02906 nrsuxe Beacon Mutual Insurance Co 0035 OISURERc.43M ESTE SURSTY 012 as nwit D Argonaut Ins. Co. INSURER E: INSURER F: 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 REOUIREMENT, 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. LTR TYPE OF INSURANCEINSR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 X commiiRaAL GENmAL LIABILITY DAMAGE TO RENTED PREMI aettnrence $ 50,000 A a ADE ®Oi�CAIR X 64457 /10/2016 /10/2017 MED EXP (Argy ate prion) $ 5,-000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPA�P AGG $ 2,000,000 X POucY PR .Wo- LOc $ COMBREERRUT-URN -(Ea acdder1,000,000 BODILY RUURY (Per person) S A AY AIS ALL OOUWNED X SCHEDULED X 64457 /10/2016 /10/2016 BODILyKMRY (Peracmlerd) $ X HIRED AUTOS X NON -OWNED PROPERTY DAMAGEAUTOS (Perapdoew) S (Medical $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,000 A EXCESS LIAR CL'4'MS-MSE L364457 _ AGGREGATE $ 2,000,000 DED I I RETENTION 10,000 _ $ /10/2016 /10/2016 $ WORKERS COMPEIiS►TION WC STATU OTH X AND EMPLOYERS' LL489M YIN I Eft F-LEACHACCDENT $ 500 ,000 ANYPROPRIETO"ARTIeREXECUTiYE OFRCER&MXA @ER EXCLUDED? � N 1 A E L DISEASE - EA EMPLOY $ 500,000 (Mandatwy in NH) If yes, descnbe uWer 70308 /17/2015 /17/2016 _ E.L. DISEASE-POLICYuhaT 1 $ 500,000 DESCRIPTION OF OPERATIONS below C Employee DishonestyF033855 358563 /10/201.6 /10/2017 SRI.= D Mass Worker's Comp 9/17/2015 4/15/2016QO r DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Auaclr ACORD Jot, Additional Remarks Schedule, It more space is nVareo National Grid is named as an additional insured on the general and business auto by policies as required sighed written contract. Av�0 National Grid 40 Washington Street Westborough, NA 01581 ACORD 25 (2010105) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AVMOPRED REPRESENTATIVE I Veerman/ml:cKr &Cit. ° CAWI � Q,�,,t`*,... ©1988-2010 ACORD CORPORATION_ Ail rights rv_cr.rVP INS6125(7ninwant Th. Ar:nDfl namn ere..! Inns nro rrnr:eFare,i+ne►4c n: Arnprf Date ........ f 2....... ............ 11065 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .......... C' � 2 ......................................................................................................... has permission to perform ...... i ^ .�` .`................................................... plumbing in the buildings of..�->...e-.� I, v e.4=� �'�- ....................: .................. at...........:.........�.........:.............,`NorthAndover,Mass. Fee ....... Lic. No. 2.` .1.?....':..1'F................................................................ PLUMBING INSPECTOR Check # P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY c9"%„/ MA DATE 3 a /S ( PERMIT# JOBSITE ADDRESSr 1` OWNER'S NAME OWNER ADDRESS ' " TEL r�_ j dt FAX OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL NEW: [I RENOVATION: REPLACEMENT:Ell RESIDENTIAL PLANS SUBMITTED: YES Q No Ell FIXTURES Z FLOOR- I BSM I 1 12 13 14 15 16 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET WASHING MACHINE CONNECTION VIIATI,R HEATER ALL TYPES PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES0 NO 0.i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY b2r OTHER TYPE OF INDEMNITY 0 BOND D --I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MassachuV I Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [3 AGENT 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 compliantith all zPerttinent:ovislon of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws.12 .�tVC PLUMBER'S NAME # ��F I / SIGNATURE MP [I JP H CORPORATION 0# PARTNERSHIP 0# = LLC Ek CITY=�u— — I STATE ZIP ®.� /p �' fl TEL ('®3 L f 417s— FAX CELLS b.7-( .1 EMAIL pC�/1C—SSCya�fGelA�uCAfCOmCr9%i�RJG�r'� o z N ❑ Iii W LL 0, The Commonwealth of Massa , chusetts Department of IndustrialAceidents M S' I Congress Street, Suite 100 Boston, MA 02114-2017 "t www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeLyibly Name (Business/Organization/Individual):r-u I�✓/1Kl,Cd`P��— 2GfC5N Address: J�3 q City/State/Zip: 0 3 108 Phone #: ,657 9y Are you an employer? Check the appropriate box: 1. Tama employer with employees (full and/or part-time).* 2. F I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ 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.] fl: Type of project (required): 7. ❑ New construction 8. E] Remodeling 9. ❑ Demolition 10 [] Building addition 11.0 Electrical repairs or additions 12. [ 'lumbing repairs or additions 13. F1 Roof repairs 14.0 Other 'Any applicant that checks box #1 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 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-cori6dors 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: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: okv MA457J 97"- �j- Aiyml f/ t'Kl - 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 required under MGL c. 152, §25A is a criminal 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. I do hereby certify under the pains and penalties ofpejury that the information provided above is true and correct. 5— Phone #: Official use only. Do not write in this area, to be completed by city or town official . City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions p 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=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 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-iii'sur6d companies should'enter their self-insurarice 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 www.mass.gov/dia n