HomeMy WebLinkAboutBuilding Permit #678 - 41 PHILLIPS COURT 4/16/2013TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINAT14
I
Permit N0: 61k, Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
77
PROPERTY1 QIIVNER� R S L.
Print 1004Year�Oltl Structure+ y- noj
MAPNO.; PARCEL ZONINGS®IS�TRICT'
T Hrstoncf,Distnct yes no±
'-77 Mhi
acne Sho Villa a es
no'
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
/-Two or more family
❑ Industrial
tkAlteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑Septic ❑+Well a
❑�Floodplaint: ` ❑ 1Netlands
, p Watersheds®istcictl,
❑Water/Sew,.er�— �...
� : __.._..:n., , _... ��_^ � .t _. .;
_ _ __
DESCRIPTION OF WORK TO BE PERFORMED:
L t L n iy A LLS -r0 C 1- o IS 1;L Ir t -i f}
Identification Please Type or Print Clearly)
OWNER: Name: CLk s COP A) 4- LL. O, Phone: v,' 19 — 0 a3 191
ARCHITECT/ENGINEER
Address:
Phone:
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: $ ello 00 FEE: $��
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to theg caranty fund
'Slgnature��of;Agenti
Plans Submitted ❑
Plans Waived 11 Certified Plot Plan ❑ Stamped Pla
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/MassageBody Art ❑ ...
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
DATE REJECTED
El
DATE APPROVED
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW 7l owe Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTME- Temp Dumpster on site yes no
Located at -124 Mair Street -
Fire ®epamerit-signafifled date °
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of (Motor location, mast or service Top 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
D (Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the app: al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm;tted with the building application
Doc: Doc.Bui?,ding Permit Revised 2012
Location_7� ��/�Qf lU✓� f
No. 4 Date
a
• • TOWN OF NORTH ANDOVER
•1}ct t
Certificate of Occupancy $
. Building/Frame Permit Fee $'
Foundation Permit Fee $
Other Permit Fee $
' TOTAL $
Check # (09 (a i
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 61000.00
m
$ -
$
72.00
Plumbing Fee
$
9.00
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
9.00
Total fees collected
$
190.00
41 Phillips Court
678-13 on 4/16/2013
Build two walls to close in area for 1/2 bath
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Re Contract
This form satisfies all basic requirements of the slate's Home Improvement Con
language to protect homeowners. Seek Iegal advice if necesstractor Law (MGL chapter 142A), but does not include standard
ary. Any person planning home improvements should EM obtain a copy of "A
Massachusetts Consumer Guide to Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the.
Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888 283-3757 or on our website.
]homeowner Information 'Contractor lnfonmation
NP/S C oX)It)6ce P4
Street Address ono se aPost Office Box address)
— q i c X 05
,IWTI own State Zip Code
LA— � I`o^0 �,��- a I
laytime Phone Evening Phone
6 i 7973iG1 612 X23 19
failing Address (it different from above)
6i -fTe (20a)UC7`„0,6
lesperson/ Owner Name
Bpsiness Address (must include -a street address)
City/Town State Zip Code
Qeralr-�-�Ploye��Mor&S.
Ole- 2-1
Business Phone Nin
Law requires that most home Home Improvement ConGetornes: Number
improvement contractors have
a valid registration number
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the workto completed, specifying the type, brand, and grade of materials to be used, use additional sheets ii'necessarv.)
Required Permits - The following building permits are required
and will be secured by the contractor as•the homeowner's agent:
(®canners who secure their Own permits'vviii be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
5
Proposed Start and Completion. Schedule -'The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
l6 l Date when contractor will begin contracted work.
G Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform, the work, furnish the material and labor specified above for the total sum of.
Payments will be made according to the following schedule:
$ upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater)
$ D a v by /L? / Z 3 or upon completion of
m ")A/ - a X-C�L .
$ thWC kupon completion of the contract. (Law forbids demanding full payrxient until contract is coin feted to bosh
p party's satisfaction) .
The following material/equipment must be special $ to be paid for
ordered before the contracted work begins in order
to meet the completion schedule.Q*1) $ to be paid for -
NOTE' & Including all mance charges(”) Law requires that any depositor down -payment required by the contractor before work begins may
not exceed the greater of (a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material
which must be special ordered in advance to meet the completion schedule.
x ress Warran -Ts an ex cess warran beim g provided b the contractor? No ❑Yes ail terms of t_hezwarrant must be attached to the contract
Subcontractors -The contractor agrees to be
party/subcontractor solely responsible for completion of the work described regardless of the actions of any third
utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and lahor under this agr6ernent
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.
o Don`t be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is uncleary
e Make sure the contractor has a valid Home Tm rovement Contractor Re 'stration. The law requires most home improvement contractors and
subcontractors to be registered with the Director ofI•iome Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 ParkPlaza, Room 5170,130ston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
o Does the contractor have insurance? Aslc the Contractor for his insurance company information so that you can confirm, coverage, or aslc to
see a copy of a "proof of insurance' document.
o Know your rights and responsibilities. Read the Important information on the reverse side of this form and get a copy of the C
Guide to the Home Improvement Contractor Law. onsumer
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 inwriting
day following the writing at his/her main office or branch Office by
third business ordinary mail posted, by telegram sent or by delivery, not later than midnight of the
signing of this agreement. See the attached notice of cancellation form for an explanation ofthis right.
DO NO'T"SZGl TM, [S c®T IF THERE
Two identical copies ofthe contract must be completed and sigaed, one copy should go to t1u h ARE ANY IMAM< SPACES contractor,
Homeowner's Siguature
Contractor's Signature
•Date � /6 %3
Date
Contractor Airbifrati,on
The Home Impiovement Contractor Law provides homeowners with the right to initiate, an arbitration action (as an
,alternative to cornu action) if they have a dispute with a contractor. The same right is not: automatically affordedto 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 flm which has been approved by
the S ecretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to •such arbitration as provided Th Massachusetts General Laws, chapter 142A..
Homeowner's Signature Contractor's Signature
NOTICE: The signatures of the parties above apply only -to the agreement of the parties to alternative dispute
resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law (MGL 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 be 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 worlananEce 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 cavy an implied warranty of merchantability and fitness for
a particular purpose. An enwneration 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
doctunents have been attached. Parties are also advised not to sign the document tivatil all blank sections have been
flied 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 rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the.payment schedule incases 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 thatthe balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fiends from said -account would require the
signat4xes of both parties,
lUditional Information '
.If you have general questions or need additional inforination about the Home Improvement Contractor Law or other
cons-am.er rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home improvement,
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Parlc Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the 0CABRwebsite at 11t ://www.mass.go - Ogabr/
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
Office of Consumer Affairs and -Business Regulation
16 ParlcPlaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HllC website atbM://www.inass.gov/oc-,Lbr/
Go online to view the status of a Home Improvement Contractor's Registration:
htij,,)•//db.state.ma.usA-iolneimproveis ent/licenseelist.asn
For assistance with informal mediation of disputes or to register formal complaints against a business, calx:
Consumer Complaint Section
Office of the Attorney General
617-727-8400 ,
AND/OR
Better Business Bureau
508-652-4800, 508-755-2548 or 413-734-3114
Version 2.1-11/22/2010
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,Y www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
7
Name (Business/Organization/Individual):(2 �S �c D `�T•�
Address: j -4o r s' ?
City/State/Zip:,
2,l LL.Ga- 2I C
kZ /Phone #: cj ?S-- 66 % — Yya 3
kre you an employer? Check the appropriate box:
❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
I am a sole proprietor or partner-
have hired the sub -contractors
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
F1 I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. .Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
iy applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
:)meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. poli6y information.
Pn iin employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
grmation.
urance Company Name:
icy # or Self -ins. Lid. 4:
Site Address:
Expiration Date:
City/State/Zip:
ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
tp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
hereby cert ainrler wins and p�nallies of perjury that the information provided above is true and correct.
)fficial use only. Do not write in this area, to be completed by city or town official.
�ity or Town:
Permit/License #
ssuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Other
'nnfnef Parenn• Phnna #T
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,
?lease do not hesitate to give us a call.
he 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
Far :U 617-7?7-77a9
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYV)
4/16/2013
VTHIS
RTIFICATE 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(les) 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).
PRODUCERCT
Insurance Marketing Agencies, Inc.
306 Main Street
Worcester MA 01608
NAME:
� Maryann Johansen
PHONE FAX
WC.No Ext •508-753-7233[AJC, No :508-754-0 87
ADDRESS:m" i as enc .co
INSURER(S) AFFORDING COVERAGE NAIC 1i
6500021717
:Art�eIla Protection1360
/23/2013
INSURED - GOYET2 -.
INSURER B:
INSURER C:
Gaoyette Construction
6 Rhodes Street
Billerica MA 01821
INSURER D:
GENERALAGGREGATE $2,000,000
GENIAGGREGATE LIMIT APPLIES PER:
X POLICY PRO- LOC
INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: 504347520 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDLSUBR
IINSR
WVD
POUCY NUMBER
POLICY EFF
MM DD YYYY
POLICY EXP
MM DD YYY
LIMITS
A
GENERAL LIABIUTY
%( COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE li—I OCCUR
6500021717
/23/2012
/23/2013
EACH OCCURRENCE $1,000,000
PREMIED—
REMIDAMAGE T R T
SES (E, occurrence) $100000
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1,000,000
GENERALAGGREGATE $2,000,000
GENIAGGREGATE LIMIT APPLIES PER:
X POLICY PRO- LOC
PRODUCTS - COMP/OPAGG $2,000,000
$
AUTOMOBILE
LIABILITYWmi"INI-10
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
SINGLE 17117T_ dern
BODILY INJURY (Per person) $
BODILY INJURY Peraccidenl $
( )
PROPERTYDAMAGE $
Per accident
$
UMBRELLA LIAB
EXCESS UAB
OCCUR
CLANS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED I RETENTION$
$
WORKERS COMPENSATIONWCSTATU-
ANDEMPLOYERS' UABIUTY YIN
ANY PROPRIETORiPARTNERiEXECUTIVE
OFFICERIMEMBER EXCLUDED? El
(Mandatory in NH)
IIye s describe under
DESCRIPTION OF OPERATIONS below
N / A
OTH-
TO Y IMI S E
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE -POLICY LIMY 1 $
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Town of North Andover
1600 Osgood Street
Bldg 23, Suite 2-36
North Andover MA 01845
ACORD 25 (2010/05)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
W 1auts-ZU1U AL;UKU GUHF'UHATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
4�
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NORTH ANDOVER, Mass. Date 11/27/ 1991 Permit # Z S .�
Building Location41 Phillips Court Owner's Name yombly
-- Type of Occupancy RESIDENTIAL
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New W Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
/Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 508-687-1105
Name of Licensed Plumber or Gas Fitter
Check one:
KI Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
64C
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Ot No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent El
I hereby certify ttiat a1:1; ofth(
knowledge aria jil�`;at a'll pl (u_-rr
pertinent provision of the tv
ttw)i
By E i II d.' —�
Title
City/Town
nrPntM_D Gc)f�tsfGT�u-�a�:
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ENT
I have submitted (or entered) in above application are true and accurate to the best of my
ins performed under the permit issued for this application will be in compliance with all
Code and Chapter 142 of the?A4—V
)e of License:
Plumber Signature of Vicensed Plumber or Gas Fitter
Gasfitter
Master License Number M-429
Journeyman
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Installing Company Name BAY STATE GAS COMPANY
/Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 508-687-1105
Name of Licensed Plumber or Gas Fitter
Check one:
KI Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
64C
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Ot No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy M 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.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent El
I hereby certify ttiat a1:1; ofth(
knowledge aria jil�`;at a'll pl (u_-rr
pertinent provision of the tv
ttw)i
By E i II d.' —�
Title
City/Town
nrPntM_D Gc)f�tsfGT�u-�a�:
A ---,1--1----X-- c._
ENT
I have submitted (or entered) in above application are true and accurate to the best of my
ins performed under the permit issued for this application will be in compliance with all
Code and Chapter 142 of the?A4—V
)e of License:
Plumber Signature of Vicensed Plumber or Gas Fitter
Gasfitter
Master License Number M-429
Journeyman
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Date. .
%ORT ..TOWN OF NORTH ANbOV.ER
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OR' GAS. INSTALLATION
This certifies that .......
has permission for gz'
Ls inst on
in the building. of
..........................
.......... North Andover,- Mass.
at
Fee Lic. 0. .......................
GASINSPECTOR
WHITE: ApPIiCanj__:—L-eA14R-Y: Building Dep t. PINK: Treasurer GOLD-.� File