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HomeMy WebLinkAboutBuilding Permit #719-13 - 437 MASSACHUSETTS AVENUE 5/1/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: I Date Received ANT: Applicant must complete all items on this LOCATION L1,37 NA SJ 11 it k INV G Print PROPERTY OWNER 2)A1\1 Gid RNC y (1�f J ��� Print MAP NO: V PARCEL: ZONING DISTRICT: Historic District yesno Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ;9 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑Well �, xx�; � 1 j_f --\•, ���d' ®Floodplain DWetlands ��,-}', r � 3 -,.�'' , Y y � „,%.,° � �Watershed�District, G3 T)-PSCRIPTION OF WORK TO BE PERFORNMD: c� d s�ii �j tf' G��fl a e/ GtF'L? 6 'T /!E c.�J -e Y' f Identification Please Tyke or Print Clearly) OWNER: Name: �/t %�/ %}0/771.'0 Phone: 9)� � ��' `7� oL/ Address: ,i.1 Ave, Y-�, Alzld vel M11 of 16- I CONTRACTOR Name: (.; G1 N 00% hh ' ` .)) d it ' �/7C Phone: c� (� j 3Yd Address: / r�i' �SL1f�1� S sieth 3A. /yd,` 7fr`'v�o' �%%d9 Gl/ Sof Supervisor's Construction License: 2g 3S 8 Exp. Date: Home Improvement License: 10V9_0 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. N FEE SCHEDULE: BULDING PERMIT: $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED 0925.00 PER S.F. Total Project Cost: $ cP�SI� °o FEE: $ �— Check No.: 26 (5- Receipt No.: Z(,O-�>qo NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 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) o 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals AL the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording zst be submitted with the building application Doc: Doc.Building Permit Revised 2008mi 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 COMME CONSERVATION COMMENTS HEALTH 60MMENTS e DATE REJECTED DATE APPROVED ❑ ❑ Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connecttion/Signature &Date Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street FM DEPARTMENT - Temp Durapster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq, ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine Doc;.Buildiag Permit Revised 2008 Location 2— t r 1 ►"`� t— No. .. Date ! 3 Check t,2 � 26341 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Building Inspector m m m m y m m v C � 5 y n O CD n Z U) CD O-0 . �sma �• N >t -0O < CD CDCD O Q = cr _ CD CD o CD CD v CL C• cQ CD 5- 0 CD O ra O CDa CD � N 1— � �* Z O c m m —1 T;O N O S > Ln R1 O X, T 5 N (n G N :10 O � S r- m x O5. S M C Z n O T d n S ( ` :;o O 3 T C :3 CL 0 =3 mcn� V7 "O = n N 3 T O O_ \ n 3 07 O T x y x Om X z Cl) 56m c cn �• 0 z O zcn 0� e� z A cn cn Z � v z O z a O O D O Z O CD N O 7 O' to O �o CD co c 0 0 CLCD o� � ., 0 o 0 coir -5. m a N CD, m n Q m � o CD �rt Q- 0 R'1 O rt CO) W CD N O CDCD 2 O O C7 co CL O N, O O CD rt O S CD 'a O 7 O CO O o� N . O 0 h •, s v D �D U oo < CD 0 C C, .� f ch=� V y rt CD p \ rt C G CC O CD CD Cn CD -� CDU) � N 0 nCD =a) CD -0 O o CL Ln O (D 0 N 1— � �* Z O W C5. j f� m m —1 T;O N O S > Ln R1 O X, T 5 N (n G N :10 O � S m m f7 Z M n 0 0 T 5. N x O5. S M C Z n O T d n S ( ` :;o O 3 T C :3 CL 0 =3 C r p Z LA m O V7 "O = n N 3 T O O_ \ n 3 07 O T x y x O y 0 DAVID CASTRICONE , UB . `ASTRICONE ROOFING & SIDING INC. ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME PAPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill978-374-7314 Uwe the owner(s) of the premises m:ntioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, io install, construct and place the improvements according to the following specifications, terms and conditions, on premises below described: ) Owner's Name ...... .......�L .41......t, . Lt . �i...�i I. .......... Telephone # .. 1 � 7 i 1 Job Address..........!. r?.�.l!..' .5....:................^ ................. City....... JG .... ..U.r:C"............. State.S J.. .......... Specifications: .................................................................................................................................................................................................... Otrip existing shingles. -140y new drip edge to all edges. it ply _�reet ice and water : hield membrane to bottom edges of house. 3 feet ice and water shield membrane in vallgys and bottom edges of any unheated areas of house. .�..........................:.................................... ..... . c -Apply felt pa er u derlayment. stall ridge vent to t" 1 A>ej"i'i X. Reroof using �Cv'fU t�.Tccr� --ci. tc� /��c;„tc_ shingles with a Ct year warranty. ......................................................:................................................ ,?Q-�nterftash chimney. New vent pipe flashing. GL�gBI disposal of all debris. .................j':......".................................................................................... Area(s) to be worked on: t ............................ .../.f..../�7C>...CtF.[.`?.......L� !:: <1.Q;�c;S� fr?�r....u..r%1fi:,,>........................................ r �' r'.iC�><l... .............`...C.l•C-4.”a.:................................ ................................................ . ir...................�06 .................................. .......... �1 nj .................. �.e..� ..:....� < .�?�..................................................................................................................................... Roof board replacement if necessary @ $bl' /sheet or 14/foot. Two Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty as specified by manufacturer The c actor agrees )o perform the work ' h the materials specified above for the SUM of $..... r Q— f .L! G / J ayable .......G�........ on .... a...� .............. ��oV Payable ............................ on..................................balance payable on completion of job Owner or Owners are not responsible for Pu.grerty Damage or Liability whIpob is in operation. Contractor is not responsible for any dama`e to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces). Items in attic may need to be cove, ed by homeowner. All materials are property of contractor. Any dumpster placed by contractor is for his use only. Upon completion of above work, all undersigned edee to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) namcs(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in`reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Unprovement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 ' & I Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A. Approximate starting date of work ................................................ Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice o,cancellation). / 2 IN WITNESS WHEREOF, the parties have hereunto signed their names this ...w�J litlay of ..�%..r1..1....., 20.,�,,,,J... Accepted: ;4igned.,f•.. ? :c.+'c :f :::»:f. ' .............. Owner Signed......................................................................... Owner David Castricone, President g- '\Ia.>aL'11u,�[[� - DcPat 'tulrnr ul Pl111111 �,afrtl 81),irtl of Buildin_ Kr ulatiun..in l tit.ir111:1r1I Construction Supervisor Spec ally License License: CS SL 99358 Restrictecl to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration 12/16/2013 TrF7924 SCA 1 G 20M 05/11 7//P rn!�boii�i'�'c/rV/ Ilii i.i!/C'�nir/�: Office of Consumer Affairs & Busidess Regulation aA. 4Om ,E IMPROVEMENT CONTRACTOR is 104569 Type: irati ,Expon: 7/14/2014 J Private Corporation DAVID CASTRICONE ROOFING, SIDING & David Castricone 200 SUTTON ST SUITE 226 _ NORTH ANDOVER, MA 01845— Undersecretary EASTERN INSURANCE Amo �'® CERTIFICATE OF LIABILITY INSURANCE 9/11/2012' F'PRODUeER 978 213 6368 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION llows Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cochichowick Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, North Andover MA 01845 INSURERS AFFORDING COVERAGE NAIC # INSURED IN9URERA,WESTERN WORLD INSURANCE_ CO DAVID CASTRICONE ROOFING & SIDING INC & CASTRICONE ROOFING & SIDING INC 11NSuRERC. 231 Sutton St F3A INSURER D'. NORTH ANDOVER MA 01845 ; INSURE RE: vTHE 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 OFSUCH POLICIES• AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.LTR INSR ADD-VIPOLICY NUMBER POT ICY EFFECTIVE POLICY EXPIRATION LRn1T5 OENERAL1JA81LITY EACH OCCURRENCE S 1000000 TO RENTED COMMERCIAL GENERAL LIABILITY t PREMISES (Ea Dcourrenga),.... �.� 50000 A CLAIMS MADE XjOCCURI pP1332888 9/6/2012 %9/6/2013 MED EXP (Any one person) $— 1000 PERSONAL S ADV INJURY S 1000000 GENERAL AGGREGATE S — 2000000 GENT AGGREGATE LIMIT APPLIES PER: i i PRODUCTS - COMN013 AGG !S 2000000 POLICY , PR : LOC , JrA i AUTOMOBILE LIABILITY I COMBINED SINGLE LIMB � � I (Ea eccidon() _ ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Pr pecan) HIRED AUTOS' BODILY INJURY NON -OWNED AUTOS (Pe accident) _ I PROPERTY DAMAGE S (Pei accident) GARAGE UAQ1UTY j I AUTO ONLY • EA ACCIDENT I$ ANY AUTO i I OTHER THAN EA ACC $ AUTO ONLY' AGG $ EXCESS f UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR I_-- CLAIMS MADE AGGREGATE Is DEDUCTIBLE I S �S— RETENTION $ WORKERS COMPENSATiDN WC STATU- OTH- AND EMPLOYERS' UABILIrY YIN I TDRY.LIJ��?.S, ER ANY PROPRIETOR/PARTNER/EXECUTIVE L EACH NT EACCIDENT $ OFFICE"EmBER EXCLUDED? a _••_.... . ... _ I (Mandowfy In HH) E.L. DISEASE - EA EMPLOYE $ II ee, deaalDe Under ----- ... ... .' ._.. ...----- S�ECIAL PROVISIONS tle10w E.L DISEASE - POLICY UMIY $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION • DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Castricone Roofing & Siding NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 90 SHALL Unit 3A IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 231 R Sutton Street REPRESENTATIVES.17 1 AUTHORIZED REPRE A North Andover, MA 01845 ACORD 25 (2009101) ©1980-2009 ACORD CORPORATION. All rights reserved. INS025 (200901).01 The ACORD name and logo are registered marks of ACORD ACa CERTIFICATE OF LIABILITY INSURANCE DATE (MMDD!YYYY) 9/24/2012 THIS CERTIFICATE 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(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 NAMEf Select DePt ext 66807: Eastern Insurance Group LLC - Main tAJ2 No 0 -651-7700 I ac No : -65 -80 9 233 West Central Street E-MAIL Natick MA 01760 ADDRESS: r i INSURERS AFFORDIN GCOVERAGE NAIC0 INSURER A:CnmmPrCP R Indimtry 119411] INSURED 31969 David Castricone Roofing & Siding Inc 231 Rear Sutton Street, Unit 3A North Andover MA 01845 COVERAGES CERTIFICATE NUMBER: 15!Ia5n19a7 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. INSRTYPE LTR OF INSURANCE A R WVD POLICY NUMBER POLICY EFF MMIDD!YYYY POLICY EXP MMIDDIYYYY LIMITS AUTHORIZED REPRESENTATIVE GENE RAL LIABILITY r OpAMERCIAL GENERAL LIABILITY CLAIMS -h9 ADE 7 OCCUR C I EACH OCCURRENCE $ A �� PREMISES Ea occunertce $ MED EXP (Any ore person) $ PERSONAL R ADV INJURY $ GENERAL AGGREGATE $ GEITL AGGREGATE LIMIT APPLIES PER: � �� POLICY PRO- i LOC PRODUCTS - COMP/OP AGG $ _ $ i AUTOMOBILE LIABILITY ANY AUTO ALL OVINED SCHEDULED _i AUTOS AUTOS NON -OWNED HIRED AU TOS -t AUTOS Ea accidern BODILY INJURY Per person) $ ( P ) BODILY INJURY (Per accident) $ PP,OPERTYDAMAGE "Pei acxk)ent $ $ UMBRELLA UAB EXCESS LIAR I OCCUR I C,IMS-MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS _ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR!PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) It yes, desciibe under DESCRIPTION OF OPERATIONS below NIA bVC003989723 /23/2012 ./23/2013 1 X V" STATU- OTH E.L. EACH ACCIDENT $100,000 E.L. DISEASE - EA EMPLOYEE $100,000 E.L. DISEASE , POLICY LIPArr I $500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, If more space Is required) I-�wr 11 -1f -A 11-r r I I new rnnrrr=r r ATInni W) 1VUt3.1010 AC:URU GURPURATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David CaStrlcone Roofing & Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 231 Rear Sutton Street, Unit 3A North Andover MA 01845 AUTHORIZED REPRESENTATIVE I W) 1VUt3.1010 AC:URU GURPURATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 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): ClaS'f R 1 LO n 1 `nyt 1 N (r 2 SI p t tz(_ \ N Address: A 3 1 R So�O to S-�ite.k .3 A City/State/Zip: Ne. 6&0 vel N A 0 1 qhs Phone #: 9 Z j (&%3 .3 yd o Are you an employer? Check the appropriate box: 1. ® I am a employer with 8 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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.] 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 I l.❑ Plumbing repairs or additions 12^ of repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_��� jS Policy # or Self -ins. Lic. #: W 0-003199 la.3 Expiration Date: 5-A3 •02� � 3 Job Site Address: q,3.:z Mn4 S Ru E ou r- City/State/Zip:_n.-n- n G , nim o i fi q 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. Ido hereby certify urn -deter the pains and penalties of peijiuy that the information provided above is true and correct. Signature: J �J Com Date: Phone #: q _�� 413 3 q�-P 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 #: Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM NORTH '9 F O o o - 13 ,f 9 roc iii w��r i SSACHI!5�� In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c.l 1, s150a. The debris will be disposed of in /at.- Z - Facility location Z) Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector,