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Building Permit #72-13 - 415 MAIN STREET 7/30/2012
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received v 3 U 2u/2 v-.ct `RD ,6T •hO� TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial eplacement Repair, replacement/XL Assessory Bldg Others: Demoll.iitiiocny Other r f . 'ie �5eptic,.., xWell '� ••.. a--.2.`�:A ei +y:.�'•f4x�`` 1 # f 'ut =Flo dplaln + Wetlands }> � , Ts..Y4 i's�' y�x� , ...�` Watershed�Dlst� riot , Water/Sewer�'. c ' DESCRIPTION OF VVURK TU fit FKh1-UK1V1hu: Please Type or Print Clearly) OWNER: Name: . /"6/f Arlrirocc• CONRA iNam '� /e. /� Y � t ARCHITECT/ENGINEER SLwe e 44,1 e *A/d lo 5236 r..ey .a1�' �* ,j'�.y-s��av��•xV.-.-.•+;, r3�'�T�.��-•'.q''".+"��"�.`"`ae'�±"'p"."'�± �+ �� '.w�. O"¢ 1TT^''..,*'.FT'..E-_Y^.r�'°`�cri•Pc: j�`er+; .yM..�F'•4�i,.'.A:�t'. t Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $10.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. O Total Project Cost: $ GG4, FEE: $ Check No.: Q O Receipt No.: C�_ S NOTE: Persons contracting with unregistered contractors do not have access tolhf guar#v fund Signature _of Agent/Ovvner _� :'.;.,.-=i_� i ,Signature of contractorx" 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 Reviewed on Siqnature 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 Town Engineer: Signature: t_ocateo ;iti4 usg000 Street ''3site DumpsteraA%tivr'i4 VT;"= Temp ,on �s ,`' h �`r••�-�'°'�'� ireet' �fxn signature/date.,':. if'►-:«.,.. R�-94�..`a,.�3:..-'[�F�,., .K .k-�+.�:-rx. �^:z`:.�+'4:::Aw:.,'_,'.es��...,_..:2.�.n,raac�r.. `'.:"3,..:.:...+:�,R?;«�'+ � �.e'ar...G 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 — ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 ent use 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 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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Location C/C— ' ' ` o/w n No. /' - 3 Date / �y TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee Other Permit FeeSv $ TOTAL $ Check # ®rA 25554 Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �^ Please Print Legibly Name (Business/Organization/Individual): �Q Yr re -14 L/ N C Address: I �t ;-4 S%Q+pe. City/State/Zip: T 2s &v2 y Hi 4 Phone #: 122do 3 /y oPk s- % Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.p I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Job Site Address: Expiration 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 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. T do hereby certify it r the pai e-�nalties 000f perjury that the information proviideed. above is true and correct. Signature: Tate. ti0 v O 2U /Z Phone #: R? �p .3/C/ %PPS' 7 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 AV. 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. # 617-7274900 ext 406 or 1.877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass,gov/dia J W x o < O mJ N Y y, \ o O LL 4) TO v) U a N Vl O IL z Z m C "O � O LL t z o d' N C E s U C LL O d z Z m a ..0 � o d' LL O d z LL U v J ui t o d' d) U N (n i C LL CC O F a Z Q C7 3 o d' C LL z ui D W 95 U. E m ocu Z CU a`+ {n E N 7M--7 uj am E L CL y t H1 O cn C m rn w vn m L O C O N d O z 0 Q J O cn z Z W w G.. w H W a. U L.i. Cl) O U N J Z a U) z z 0 J M= W w ICLO O V .4+ L a do Q ar :° y V �E4 L y _ d C� .O i Co O y -Nr N yi y J � L foo z as CL An o 0 '� _ �. 3 o0 L Q CL d� 0 __ m +0+ .y _ C CD a i O = % i cc 'a _ C a> v m N CD W C O O LL 'nd Cc C .� t O v v W V £ v � c L O N U) y •>w• C O F- t Z QOL) E L CL y t H1 O cn C m rn w vn m L O C O N d O z 0 Q J O cn z Z W w G.. w H W a. U L.i. Cl) O U N J Z a U) z z 0 J M= W w Page No. of Pages STEPHEN M. KEISLING Building & Remodeling 9 9th Street West Salisbury, MASSACHUSETTS 01952 MA Lic. 027489 Home lmpv. 101846 Phone (978) 682-2072 Cell (978) 314.8457 PROPOSAL SUBMITTED TO A7-lz f `F PHONE DATE ao 12 STREET JOB NAME CITY, STATE and ZIP CODE � n t//t).,. � c` JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: ,Z- 3 + c6Q-.tl We proPOSP hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully covered by Workman's Compensation Insurance. Authorized Signature _ dollars ($ -27. Note: This proposal may be withdrawn by us if not accepted within Arcrptaurr of Proposal— The above prices, specifications I— and conditions are satisfactory and are hereby accepted. You are authorized Signature —a, to do the work as specified. Payment will be made as outlined above. v Date of Acceptance: �� g Si nature days. I' 1 I ...1'f c�;�`•al ,� r �: ^..I ! fig' . I:Il1Ira. M� �30fedhma30Ag8ig Sa�Ct�advioeTYey. eesnaaa�tdoamn�eibstOAmeTimce�) a�� ylfovm sae 7�PCade Addnas asoaetzdd. Alp . "a t ew `� E�i� Tpcode Y2 3 re�GtS Eve ,� lJ/f?S'2 �r�s�rTo�ss.l� / -- .1 ca cam . aaappai'A -�T�ase�d �r�edt�aadc_ esamedbyQm m&e sao& be t, d aase 3wfat thdrawapumftwWbv I S+am tt Gmmaasty Famd pwi* lm or D�iewgm a � beta aost�edamh mptw 147A.) teastPrlees� isy�ee nsara�+xstoa��e.r�temi�tQenasu��,a�.L,.._._. ` _� Fayoamtswiltbem3h�omd to fOltaarmgs 3(narmaoeedil3�the�loo�zQPace�rilxcaatof vodd fteomwhickayspEta). 7 Ar T.t L1.4 %ion o f SAow - S by _/- ! � �aft4ea�. (Iaavfaxf�t��y�g�d.sevmpdatd�L� Fact9's) �mmtuospmat S mtbegsiasS mdaedbefinefi5emm�edcadc6t,�j�i¢mda tomeetd¢e��� ; m�padior rem -M> Odt-ft�f.�tmn,�is�rdepa�cardbstheomunrmr8e5�ea�5�r cf �do4�emndPoa(b)�e»mlonQof�YYeparas�mpm a4iehomtbespaid asn®esdme� -'Them+mrtobrso�i9retaraomof�er,�t ��afasyfhl�ld otr�dbythea'iheafiu@�eragitestobtsatdyforaHtoaQ�boaa�r aadb�or�a�t Reeieff aaefiowiggean amisosifles o. I1mltLe i�D Td'Td 'fi=t--&i-dfiftumbWmdiL Asl[ if s Ad�esvei&ebaaavalid�L„�.*-- R.��;,,� iseerles tnbere wtlhdxl7mxtor�HmselY bm� aoa aa=d bYwri�gm$tti ailOPmkPlaot� Raom517t�Ba�a.BdA@ltdit u' abourtomuectr o URes�ommta�imve Aardse�bs� bY�II861y�9�387g1or»3-3757. ' seese�y�a'pmefafa�uacce"d�t ysodffitpoa��aam�,mra�6a u K=wYmwdglftmdnwnoffdm Remldwkvmtmt =theiererseaideofWs immaadT;,elaaapyaf�Co�mer CmdemdmHmee lzm Ywmayemaida a ifkhrsbeeaskmda;admdeeam mwsnm,.i in3� �e coat>mtturwrasgalhs4hamaiea>�oeorbta�hoffioehymdu ymA by smiarby Malaw9mai K&e 8mdbasa dsY es mg�� Sxdacet ed iaeefcmcdkf=fozmfbraa offt - BQ NOT SIGN T11iS CON!'R CF IF TBERE ARE ANY K ANK SPAt MI! T idwTi.dw.d.. - 6WAV`— --••r•••••�,,.,�, wac�Fasaa�6��Fsaoo� $a@asa�}rs�OnS{�{�ptbydsa�•soaz - aQiEe6WE>Q'Stl� S 7�/�— Zp/2 % l�' 2o/Z Thai Dde -T. ♦.....,- _ .Imo....,-,..- „ r _ _: J.... L _ .:.4 1 . N.f T. tt to initiate an arbitration action (as an "ice =t automatically afforded toa scf 4'r 'TM i viati4Livi .;yrsµ I---- •«.. 7-=!= :!-Lspute he/she has with a homeowner in court unless .. —CC _J_.t a.. +L_ L——_—�_. L.. cif.._ TT_..._ T...._.._ suer. iiu iu v.ay...v.. w aaa.. uvaus:a.--za:.: v� :..._ z_.a:au: :u y,--Vement Contractor Law. The contractor and the homers zia hereN mut4a.y 4pb ua iiuviww 'u,a M W, �:wu iiye i�utractorhas a dispute concerning this c ontrut, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, djaptgr142A Homeownces signature Contractor's Si NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the comtivew. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. A bomeowner's protection laws (Le- MU chapter 93A) may not be waivers in airy sway, ever, by ag;,;� llr:*civ.,:, Wurwo w;�::, • e.' -.. ♦ . • r.t. _ _ _ j't:.ys ..,.,,...=M i—enApropedyiegistered as presrn`bed bylaw. nc=fts are automatically excluded from all Guaranty Fund provisions of -r.� , �:- <.„z . ,~ 1--w. ua coa ac:” is responsible for completing the work as described, in a ;,=8 maybe entitled to other specific legal rights if the contractor guarantees or provides as express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terms ofthe contract as long as they do not restrict ahomeowner'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"cate. and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been . filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments iq 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 workmay not begin until both parties have received a filly 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 in cases where the homeowner deems Wmlhcmlfto be financially insecure. However, in instances where a contractor deems himrUmlf to be financially insecure, the contractor may require that the balance of fimds not yet due be placed in a joint escrow account as a prerequisite to continuingthhe contracted work. Withdrawal of foods from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if yon 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 Pads Plaza, Room 5170, Boston, MA 02116 617-9734787, 888-283-3757 or visit the OCABR website at littp:/h%%-w.mass.eos•/ocabr/ 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 10 Park Plaza, Room�5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HIC website at littr)://%vw%s.mass.eov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: littp://db.state.nia.us/lioiiieiniprovement/licenseelist-aso For assistance with informal mediation of disputes or to register for hal complaints against a business, can: Consumer Complaint Sedion Office of the Attorney General 617-727-9400 AND/OR Better Business Bureau 508-6524800, 509-755-2549 or 413-734-3114 Vasion z.n - r urnrmuo Office of Consumer Affairs & Business Regulation kWME IMPROVEMENT CONTRACTOR j egistration: , 0 46 Type: piration: �;6/29I20�14 Individual T 4, ,.• t _ STEPHEN M. KEISL�NG - ., � ! Stephen Keisling !Ir 9 NINTH STREET ``�,;, :=�'-/<a• ��}_ SALISBURY, MA 01952 Undersecretary a Ems' v ..t a -�• II t•«• .i r e . £S Ems' ..t a -�• r e . FARM FAMILY CASUALTY INSURANCE COMPANY Issuing Office - P.O. Box 656 • Albany, New York 12201-0656 CONTRACTORS ADVANTAGE ® DECLARATION PAGE Policy Number: 2005X0431 I . Name and Mailing Address of First Named Insured: 1 1111EPHEN KEISLING Y 9; 9TH ST W BOP000916907 Agent No: 3485 Agent Phone: 978-887-8304 UGONE JOHNSON INSURANCE AGENCY, IN 7 GROVE ST STE 201 TOPSFIELD MA 01983-1862 SALISBURY MA 01952-1702�.a The Insured is: INDIVIDUAL Transaction T e• RENEWAL yp---Transaction Effective: 03/21/2012 Policy Period: From 03/21/2012 To 03%21/2013 d 12:01',A.M. Standard Time x -P V" Business Description: CARPENTRY - ;Total -Limit of Liability Term ADDL/RTN, "i Business Property Coverages Premium Premium Y; Buildings ` Business Personal Property Business Income and Extra Expens , $5,000 $22.00 p ;. Actual Loss Sustained Not i, 'Exceeding 12 Months tu7iker Endorsements SEE SCHEDULE BUSINESSOWNERS LIABILITY j ,r ' Except for Fire Legal Liability, each paid claim for the following<coverages reduces. the lamount of insurance we provide during the applicable annual period. a . ° t t Business Liability Limits of Insurance Bodily Injury/Property Damage $500,000 EACH OCCURRENCE $1,000,000 AGGREGATE j $1,000,000 AGGREGATE FOR j PRODUCTS/COMPLETED Medical Expenses Fire Legal Liability Other Endorsements OPERATIONS HAZARD $5,000 EACH PERSON $50,000 ANYONE FIRE OR EXPLOSION SEE SCHEDULE POLICY SUBJECT TO ANNUAL AUDIT: YES TOTAL PREMIUM The Declarations, Schedules and These Forms and Endorsements Make Up Your Complete Policy: BP00021299 BP00060197 BP00090197 SP04170196 BP04190689 BP04961001 BPO5140103 BP07010197 BP10040498 BF30061103 BF40380902 BF40390303 BF40861010 BF40910708 BF40921010 BF40940610 BF41090204 BF41321008 F199020108 Countersigned By Page: 1 of 2 Authorized Representative ANX-3190 INSURED COPY Processed Date: 02/14/2012 NORTH ot 'q N 0 -'N Date. TOWN OF NORT ZANDOVER PERMIT FOR PLUMBING This certifies that .... ... .. .............. has permission to perform ..... .............................. plumbing in the buildings of . A-- .................... at ............ �North Andover, Mass. Fee /—/`/`-."Z Lic. No. .. .......... -t ...... ....... P L U MAB I I?G"I N S P E CTO R Check 4 8250 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date 1 3/ J Building Location 1" „¢ tS/ t Owners Name �{ ��r , C Permit # DI's -0 Type of Occupancy Amount New �" Renovation Replacement ri Plans Submitted Yes No ❑ 01 Wq K W • NowI / , `0100I M..------ -.-.RMUMMMMMU ..-..�.-.- 1 13 ' -.-----�--M--.-...-.-M.MMMMMMMM -. MM Will f �:' ..-----.-.----�.---.--.-- 1 4:' ..-..--...----M.M.. (Print or type) — Check one: Certificate Installing Company Name 2 . / � M - "P -,e Corp. Address � iJ �-- �' Partner. Business Telephone z J ©' Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0- Other type_ of indemnity ❑ Bond ri Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work Wslatio performed under Pe 't Issued for this application will be in compliance with all pertinent provisions of the Mas to Plumb Code a Chapter of the General Laws. By'Signature 01 License -1u er Title Type of Plumbing License City/ icens um er Master 0/ Journeyman APPRORO VED (OFFICE vsE ONLY Workers' COMPensation WWW-HWssgrov1dia APPlicant Information Im4rance Affidavit: Iguilders/COntr*actors/Elec-tricians/pimbers Please Print LeeibE, Name (I3usincss/()rga0j zation/Individual):_ Addnss: citylste&zip: Phone k. Are you an employer? m.t, 4& eappropriate box: 1 am Z employerwith 4, 1 2M IL general The Common wealth of Massachusetts k1 l , ItV46!'Re Department Of IndustrialAcd&ft Office Ir I I of Investigations J/1 600 Mashin.Mn Street working forme M any capacity. Boston, M4 82111 Workers' COMPensation WWW-HWssgrov1dia APPlicant Information Im4rance Affidavit: Iguilders/COntr*actors/Elec-tricians/pimbers Please Print LeeibE, Name (I3usincss/()rga0j zation/Individual):_ Addnss: citylste&zip: Phone k. Are you an employer? m.t, 4& eappropriate box: 1 am Z employerwith 4, 1 2M IL general Type of projee' (required): employ= (fun and/65Tr�__time).* 2.[3 1 am -a-sole PMPrietOr or contractor and I have bired the stab -contractors New construction partner- Ship and have no employees listed on the attached sheet 7. Remodeling working forme M any capacity. nese Sub�contractors have workers' insurance. 8- 0 Demolition [No work=, comp, insurance comp. 5. ❑ We are a corporation and its 9. n Bu . ilding addition required.] 3-13 1 am R homeowner doing officers, have exercised their 10. D Electric" repairs or additions all work myself, [No -workers' comp. right of exemPtion Per MGL -C. 152� § 1(4),'and we have no IL Plumb' ing rePRh or additions insurance required.).t employees. [No workers' Roof repairs *Any applicant am ChMh bwe# I comp. insurance required_) 13.[ ].Other Homeowners who Mllnnit this Out the ail indicating they oun ch=k this box r"USt aftahed seefion WOW showierg their VM eri, . rk COMPMS01CM am doing all wMt 2nd then him outside con contractors policy information, roust'submit en additi "j sheet showiltg. Me Inum of dc sub-mtrwo� d .AnCWAffidAvitindim*,ul, 1 sin as employer fif at iSPrqVi&nr:woFkMM, their Woria-M, comp. for"z2fion. ift$urmcefor my ens ye= Below is &eP09cy and job site Insurance Company Name: Policy # Or Self -ins, Lic, 9: ExPirstion Date: .Job Site AddrMs: ------------ Attach a copy Of the workers'city/swcolp. Failure 10 cOmPeumtion Policy dechtration P152{can ShOwin.9 the policy number and expiration date� fine up to secure coverage as required under Section 25A of MGL C. lead to $17500-00 and/or one-year imprisonment, pnsonment, as well as civil penalties the 'mPositiOn Of cruninal MahiM of a, Of up to S250.00 a day apinst-the violator. es in the form Of a SMP WORK DIZE) Investigations of the DIA for insurance coverage ER and a fine Be advised that a copy of this statement may be flarwarded to the Office of verification. Ido hereby certify the e ppainsand penalties 0 fP`eljwy'that the informWORPrOvided above isSi lure: true and rowed Phone 9: Of,r'cW use only. Do not write in ---------- d by city or town official a' City or Tow ui ing A Permit/License Issuing AEtthorhy.(circle one): I- Board L Board of Health 2- auildiRg Department 3. City/Tovvn Clerk r 6. Othek -------------- 4. Electrical Inspector 5 Plumbing Inspector [Contact Person: Phone #. Information a. Ad. Instructions. 's Massachusetts General Laws chapter 152 requires all emp Ioyem 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 mom of the'foregoing engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the receiver ortrustee -of an individual, partnership, associatiozn or other legal entity, employing employees. 'However the owner of a dwelling house having not more than thrm apa rtmen s 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 t or permit to operate a business or v 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-=eptable evidence of compliant: witb the insurance requirements of this chapter have bean presmiled tv the contracting authority." . Applicants Please fill Ott the work=. compensation• affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), addimss(es). mind phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, arc not requtredlo carry workers' co mpensation insurance. if an LLC or UP 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 lbe sure to sign and -date the affidavit The affidavit should be returned to the city or town that the .appRoation for.fiz permit or license is being requested, notthe Department of Industrial Accidents. Should you have any .questions regar%fing the law or if you are required to obtain a workers' compensation policy, please call the Depwtrient at the nwmber listed below, Self m-su-red er, iec should ent their self-inswan=—Hemse number on the'approprim 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 whichv%-ill 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 indicatingcurrent policyinformation (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 furore permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen i obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit'to bum leaves etc.) said person is NOT required to complete this affidavit, The Office of Investigsations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a tali. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of 130dustrial Accidents Office of Lnvssti;eat ions 600 Washington Street Boston, MA 02111 TeL 9 617-7274900 ext 406 or 1-977-MASSAFE Fax 4 617-727-7749 Revised 5-26-05 wrwW,m.Dav/dna 0 Date../ ..-.� .-.n? ...... TOWN OF NORTH ANDOVER _.3 0 PERMIT FOR WIRING -This certifies that ...... ....................................... has permission to perforriL . ............... wiring in the building of.. ....................................... A at ...... ................. ... North Andover, Mass. Fee...:?/Ii......... Lic. No. ............... . Check # ELECTRICALINSPECTOR Commonwealth of Massachusetts Department of Fire Services low BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. / �ks–C) Occupancy and Fee Checked G , [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Q 0 City or Town of: NORTH ANDOVER To the Inspector of , ires: By this application the undersigned gives otice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant �•h ' -elephone No. Owner's Address �i !a•r�� Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes LJ No 144"0" (Check Appropriate Box) Utility Authorization No. 7-3—.! ��S- Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical _11Work: ��rjg s Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- o. o mergency Ig g 1 g rnd. ❑ rnd. ❑ Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection an `Ob Initiatin Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices Heat Pum Number Tons ... KW No. of self -Contained No. of Waste Disposers Totals -••' ' ' ' """•••"•••• Detection/Alerting Devices No. of Dishwashers Space/Area HeatingKW Municipal Local ❑ Connection ❑Other No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo.of No. of No. of Devices or Equivalent Heaters KW Signs Ballasts . Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: OTHER: l� EY AA U3-7 No. of Devices or Equivalent �® Attach ditional detail if desired, or as required by the Inspector of Wires. Estimated Value of 4lectcal Work: (When required by municipal policy.) I` Work to Start: %D / t)Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabill insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cqvgfage is in force, and has exhibited proof of ame to a permit issuing o ce CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 12�l1vi I certify, under the pa_in�s enalties l perj ry, that the 'nform o t is application is true and comple FIRM NAME: ,d !� l t LIC. NO.: Licensee: h h U Signature LIC. NO.: (Ifapplicable, enter exemp, , i the license number line.o ) Bus. Tel. No.: Address: lVt'! 1 G lit Lt h Alt. Tel No. *Per M.G.L c. 147, s. 57-G1, security work r uires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ m 1 r I 0 -1 Date ........ — .... ... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that1� ............. 4,v ............................................................ has permission to perform ............. 4 ............................................. wiring in the building of .......... h ............................................. at ............... ......... . ............. North Andover, Mass. Fee.3-:F..- Lic. No. .............. /L Check # 1v (,1m w1wealth o� MaesacL"M Official Use Only cc/� cc77 Permit No. eCJeParfinen� o�.}ire �eruice� — --� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07) leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ), 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE LL TION) Date: (J U City or Town of: () To theInsp ctor of Wires: By this application the undersigned gives notice of his or her intentnto perform the electrical work described below. Location (Street & Number) �j6 171f'l 4lSr- 40 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes EL Purpose of Building ly Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. Overbead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Com letiono th 11 No. of Meters No. of Meters nrracn aactitionai detail j desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such eo�;�ere is in force, and has exhibited proof of s e tp the,�rmit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:)«�//wp�J I certify, under the pains enalti o per ry, that a information on happlication U � f�� l �e .f rs true and completes ��� FIRM NAME: / &ZE LIC. NO.: Licensee: SignatureLIC. NO.: (Ifapplicable, enter " em " " the h nse number linvy I>� Bus. Tel. No.-, _ Address: `G e -11G/ Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work quires Department Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. S 3 <uute muy oe waivea oy me ins ector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- ❑ A. o. o cy ig ng nd. Batte Units Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. Detec—Initiating tson and Devices No. of Ranges No. of Air Cond. Tot Tons No. of Alerting Devices No. of Waste Disposers Heat ump _._:um.___er_ .. ons o. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMun'c'pal El other Connection No. of Dryers Heating Appliances KW Security Systems: No. Devices Equivalent No. of Water eaters K No. o. of or Data Wiring: as ts Si s Ballasts SiW No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No, of Devices or E uivalent OTHER: nrracn aactitionai detail j desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such eo�;�ere is in force, and has exhibited proof of s e tp the,�rmit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:)«�//wp�J I certify, under the pains enalti o per ry, that a information on happlication U � f�� l �e .f rs true and completes ��� FIRM NAME: / &ZE LIC. NO.: Licensee: SignatureLIC. NO.: (Ifapplicable, enter " em " " the h nse number linvy I>� Bus. Tel. No.-, _ Address: `G e -11G/ Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work quires Department Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE. S 3 TOWN OF ANDOVER ELECTRICAL PERMIT FEES (Effective March 12, 2003) cov NO SE CABLE ON OUTSIDE OF BUILD.TNG Air Conditioners: $40.00 each Alarm Systems Security: (for fire systems see smoke/heat detectors) Residential: $40.00 Commercial: up to 10 Devices $60.00 additional devices over 10- $1.00 each Carnival Equipment: $50.00 each Ceiling Fans: $1.00 each Commercial New Construction or Alterations: $100.00 per 1,000 Sq. Ft. of Construction Space Commercial Service Change/ Repair: Must have Utility Authorization Number $100 (first 100 amperes or fraction, one meter) a) each additional 100 amperes capacity or fraction. $30.00 b) each additional meter $25.00 Commercial Temporary Service: $100.00 Must have Utility Authorization Number Commercial Repair and/or Maintenance Permit: (Blanket Permit) up to 2 Electricians $150.00 per pair of Electricians over 2 $50.00 Data/Telecommunication: Residential: $1.00 per port Commercial: $30.00 up to 10 devices over 10 - $1.00 each Dishwashers & Disposals: $5.00 Each Dryers: $15.00 Each Emergency Lighting (Battery Units) $ 1.00 each unit Feeders or Sub -feeders: each 100 amp capacity of fraction thereof Residential: $5.00 each Commercial: $15.00 each Gas/Oil Burners: Residential: $20.00 each. Commercial $20.00 each Generators Residential & Commercial: a) including photovoltaic & generating Equip Per KVA $1.00 b) un -interruptible power systems, per KVA $1.00 c) batteries over 100 amp. hours, per cell $1.00 Heat Devices: $1.00 each Heat Pumps: $40.00 each Hydro -Massage Bathtubs/ Hot Tubs: $20.00 each Lighting Fixtures $1.00 each Lighting Outlets: $1.00 each Major Appliances: (not listed) $20 each Motors: (per hp or fractional part thereof) $2.00 Oil /Gas Burners: Residential $20.00 each Commercial $20.00 each Office Furnishings: per circuit $10 (Relocatable Partitions/Cubicles) Outlets & Fixture: $1.00 each Ovens Built in/Counter Top Units: $10.00 each Panel Change/Circuit Breaker: Residential: $20.00 Commercial: $25.00 Phone Jacks: See data/telecommunications Ranges $15.00 each Receptacle Outlets: $1.00 each Recessed Fixtures: $1.00 each Re -inspection Fee: $25.00 Repair to Service Residential: $20.00 Residential New Construction (Dwelling): $220.00 (with service up to 200 amps) Must have Utility Authorization Number for services over 200 amps see below a) for each 100 amps capacity or fraction add $20.00 b) each additional meter $10.00 c) each additional panel/sub panel $25.00 Residential Additions/Alterations: $220.00 maximum Residential Service Change or Underground Service: $40.00 Must have Utility Authorization Number a) one meter, up to 100 amp capacity $40.00 b) each additional 100 amp capacity or fraction $20.00 c) each additional meter .310.00 Sewer Ejection Pump: $25.00 Signs: $25.00 each ballast Q - Smoke & Heat Detectors & r Initiating Devices: 4,> Residential: $1.00 each Commercial: $60.00 up to 10 devices over 10 - $1.00 each Space Heaters: area heating $1.00 each Sub -Panel: $25.00 Swimming Pools: Residential: Above Ground: $25.00 Inground: $50.00 Commercial Pool: $100.00 Switches: $1.00 each Temporary Service: Must have Utility Authorization Number Residential $25.00 Commercial $100.00 Transformers: a) capacitors, Per KVA $1.00 b) ducts, conduit & conductors A (Associated w/ Padmount Transformers) $� c) each manhole $10.00 d) each handhold $5.00 e) per KVA $1.00 f) primary feeders, $25.00 each (ovc 600 volts, non-utility owned) g vaults and equip. $25.00 each Washers: $15.00 each Waste Disposals: $5.00 each Water Heaters: $30.00 each *F®r Multi -Family & Large Commercial Pro* see Wiring Inspector for., pricing: r :Paul Kennedy (978) 623-8306 (Office lours 8 ani to 1.0 ani) *Iuspecti®u Schedule: 1 SOUGH 1 FINAL 1 TRENCH (if applicable ADDITIONAL INSPECTIONS *$25.04 (i applicable) (revised 07/05)