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HomeMy WebLinkAboutBuilding Permit #57-14 - 45 BRIDGES LANE 7/17/2013 BUILDING PERMITc "°RT" qti TOWN OF NORTH ANDOVER �O 2 y6,i1�. <..a, +6�L .,� - �- APPLICATION FOR PLAN EXAMINATION a Permit NO: Date Received 4 `�~°`••�`~ '` �gss,TEo 5�;�.c5 Date Issued: _ �' '{ ACHU IMPORTANT:Applicant must complete all items on this page rLOCATION TS BIc�q"es LN - r µ°jc Pnn. , .PROPERTY°OWNER m i - o X MAP NOPARCEL� ZONING`DISTRICT Historic District - yes., no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi is Non- Residential New BuildingOne family Addition Two or more family Industrial teratio No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other 'Septic E WeFloodplain _T Wetlands - .V1/ater5hed Distncf Water/Sewer. DESCRIPTION OF WORK TO BE PREFORMED: r k1'7—CXe,AJ R-eock J /tJew 6qd;i�e7'-T Ccsvt.r erJ' h irNc Identification Please Type or Print Clearly) OWNER: Name: Phone: 970p- Address: +r77 CONTRACTOR Name . � �/�� Phone` ��?� ' a�.� -�`�' } �t a j 'Address o20� !�UM19 � Construction�License � 4� �/ ,.e, _Exp =!Date; �• 3 Home ImprovemenV icense `� 7�N�o Exp. Date .. i ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $/t t ITO FEE: $ - �— Check No.: � Receipt No.: 4A NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of-Agent/Ovvner. .u, y Signature of-contractor i ' Location j No.0, L Date '717 / ` /Y i • - TOWN OF NORTH ANDOVER • S�.�xGED�j646 . , Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL Check# 2 O 6 4 Building Inspector 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 Priv ,e septic t ,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 Signature COMOENTS 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: Located 384 Os ood Street FIRErDEPARTMENT Temp,Dtimpsfer on site eyes no L&c ited,aU,j24Q6in"SStreet' d1date _ _4 partment signatur _ Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date i Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits 61"Building Permit Application Workers Comp Affidavit 2-� Photo Copy Of H.I.C. And/Or C.S.L. Licenses u--"Copy of Contract door 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 MFORM07 Revised 2.2008 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost W 32,250 m $ $ 387.00 Plumbing Fee $ 48.38 Gas Fee 100 comm. $ 100.0Q Electrical Fee $ 48.38 Total fees collected $ 583.75 45 Bridges Lane 057-14 on 7/17/13 Kitchen Remodel I,/la sachuxetts- Depar-trttent Of Public S;ti0' Board of Buitdiniz'Reaulath3n.a"d Stanti.,rtIa Construction Supervisor Licens 1_icense: CS 48810 r t R V- BRACttt ov JR 22 WY`1UI���LANTAN DANVILLEM, Expiration: 8/3/2013 f umm �ivner' Tr#: 379 ,;TI � . Office of Consumer Affairs&B mess Regulation HOME IMPROVEMENT CONTRACTOR Registration: -4 422776 Type: Expiration: 4k162014 DSA g=_ B POWERS QZ-eft e BRADLEY POWE 22 WYMANS LANDI DANVILLE,NH 03819`'; 8% Undersecretary 1 �/xT,PeN �/Iov1sNG� Cl/'.l��UNd'f'�of` �'NaC fvJr�N% �iVe "'�`ao %CO �a.� Payment to be made as follows: dollars($ • ). Is 7 A PN 7- b?aosiT' .01 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 specifications be- Authorized L��9 low involving extra costs will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, acci- dents or delays beyond our control. Owner to carry fire, tornado and other necessary Note:This proposal may be withdrawn b us if not accepted within v days. insurance.Our workers are fully covered by Workman's Compensation Insurance. y P Y I We hereby submit specifications and estimates for: �P�„rro�e/ i Tc� N -- mf,vor /4ya�r- c�QN9e r J91�oi2� S UPP/i esu tTo sp 4 c lieg7"e JoG4T/oN p ov,-- S To rP�/scle— is Ti.- I*nTW- ln ,UaTe � &Vork wiTk e (isri'Nj "Nc �� e, ex�ase� � t c� i/J �U r� C -� -- em`'i sere. rtla 64:/y Cle U ooc► T'c //'j o Ti'/e. GJ/� . e X r S Tim q T p e rr lv/N Will &e,.. 'byeXiSi-r& Ti 4--. --- C eo%N ' w All jJy?'c� �Jo )rue/��es � or/Y)97eri9� 'prirNe% Sl�10©j �rN�Sh CR doe, / I N-ew C9�iNe s! 9r�Gu�re.��ylov/a�i;��sgf'P0 /oafe_ eNcQ '019 e.IS Tv sCr,b� .�"x aSe4�� -/a5" o 3�)a D -- ��Ye. CQ s-e oQ ©�er�ri+.�c� �`cl (,�.t�}// �'Ve/v �}�/>rQx_ 3�• 3 ao, j v s T;// �J4G ksPl�s Tie_ , ?%.e � No �/vClvc�e� �ovT div �or� cam., �t�c� /Nc/vGdrs���a�- C /Vor74 /Ao®� ��. Ps,4.1 r r� -CroN 7- ///d�c� � 'N� /l1a7-e ; jetflo -C da<rg ?rim PJAere- NE'CeSs�/ . /Ud P9�Nr/N -- i�vrel:r i'N To p r'ic c-,/U0 �4�%ive%.l Cr>uNirr J�j 9rd�v��r� or 4dr�i'77oN4/ CNork NoT/fe/vriaNe�Q C�jiv 6e. /.�i//e��3 ?` S�r/fi��2 �'/Y1�9Tc�i9 Acceptance of Proposal —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. P e t will be m/de as outlined above. Date of Acceptance: Signature I l —-- - - — - - - - To Reorder Cell,-NO.225-M PRODUCT 216 ��II�II��II Page No. of Pages 77) BRA® POWERS CONSTRUCTION 22 Wymans Landing DANVILLE, NH 03819 (603) 642-6428 PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY,STATE and ZIP CODE JOB LOCATION t.. ,pelo ve r /flif ss ARCHITECT nt C r DATE OF PLANS_ JOB PHONE We YQ iCH hereby to furnish material and labor—complete in accordance with specifications below,for the sum of: NORTH oven of � . : over No. NLAK . h , ver, Mass, 1 02 COC NIC"t-CK y1' 4A 7r, S u BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT �, ......,, BUILDING INSPECTOR . .. Foundation has permission to erect.......................... buildings a.. �............. i r�•. .. ...................... '..,'. Rough to be occupied as .. `.. ..... ...... . ..1........................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TAR Rough Service ............... ... .... ... ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Massachusetts Home Improvement 7, Contract This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A),but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first 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 1488-283-3757. Homeowner Information Contractor Information arae 'ompany arae Ins. ?gNe7"WerrBRlber-S G-v/VJrruC7y''0 Street Address(do not use a Post Office Box address) NJ Contractor/Salesperson/Owner Name 4J S rid es LN 811W v vers urryi tt own State Zip Code usmess Address(must include a street address) Nvo ori Vet- N/J, G/y�S as w /vtgNs A/ydo/N Daytime Phone C f Evening Phone iq,[l own 17/7,?—17OR V�/�� ��^ State Zip Code 9 3X9.5 ��►v>//e /i// o 3,P19 t^AO Mailing Address(It different from above) - usiness Phon / /1 a dpo .3 - andal Employer ID or S.S.Number T 4 l0 'T law rrq,ares agar mon home I acme C—M.,nes.Numher Esp-6.due ' pra"meat eoaVamap havP�Ude s J -7 / The Contractor agrees to do the following work for the Homeo net aero"��� / O. 7 7 to e m a m e e r mg a ly Pe, ran U, a at 0 1m en, o c fC��>"C�cN 1"-ev�o�e Ne>N r // c�6,'NeTs, Co�,., ���J� `�F/' 'sNCeq Cel/,, �j a/7-11 /J -e rin��C �'o�TjPriNp. F�d� gda0i`T%oN�t I �iTiN�C ' a UT/ers- Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their own permits Will be excluded from the Guaranty Fund provisions of MGL chapter 142A.) a '/&Date when contractor will begin contracted work 8'/9/3 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 /tL✓ (+) Payments will be made according to the following schedule: $ do upon signingcontract(not to exceed 1/3 of the total contract price or the'cost /of+special order items,whichever is greater) $ �o� by Z/o�//J3 orupon completion-of_ -ii rsr (��y ©T "ark b-el"100 $ by _/_/_ or upon completion of Demo, Re f/g/1 $�las, upon completion of the contract (Low forbids demanding full payment until contract is m completed both party's P satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted work begins in order $ to be paid for to meet the completion schedule.(**) NOTES:(•)Including all finance charges("+)Law requires that any deposit or 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. Express Warranh,-Is an eecc warranty being provided by the contractor? Noy (all terms of the Subcontractors The contractor a must be actioned m the third contract grecs to be solely responsible for completion of the work described re party/subcontractor utilized by the contractor. The contractor further a all pa ss en the actions o any third materials and labor under is agreement to be solely responsible for all payments to all subcontractors for 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 • Don't be pressured into signing the contract Take time to read and fully understand it Ask questions if something is unclear. • Make sure the contra_clor has a valid Home Improvement Contractor Rr 'stration. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933. . • Does the contractor have insurance? Check to see that your contractor is properly insured. • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Homo Improvement Contractor Law. Emn ycancel this agreement if it has been signed at a place other than the contractors normal place ofbusiness,provided you notify the tor in writing at his/her main office or branch office by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the usiness day following.the signing of this agreement Seethe attached notice of cancellation form for an explanation of this right D NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! '11.iderdi I copier of the eontract must be completed and s' ed One copyshould go to the home-neer.The otthherDcopy sh t by the contractor. Homeowner's Si mature Contractor's Signature Date J Date .. t Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to 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 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 bmit ch ' tion as provided In Massachus General Laws,chapter.142A. Homeowner's Signature Contractor's Signatu NOTICE:The signatures of parties above apply onl the agreement of the parties to alternative dispute.resolution initiated by the contractor. The homeowner may initiat 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 firom all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike 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 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 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 du licate and should not be signed untila 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 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 recission 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 him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds 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 you wish to obtain a free copy of "A Consumer Guide to the Home Improvement Contractor Law,"contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (6I7)973-8787 or 1-(888)2833757 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 Bureau of Building Regulations and Standards One Ashburton Place,Room 1301,Boston,MA 02108 (617)727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 07/16/2013 13:38 FAX 603 382 3387 JOSEPH HILLS AGENCY INC Z002/002 � 1 POWDBA1 OP ID:ST ArR�n CERTIFICATE OF LIABILITY INSURANCE F7707116113 TE ) 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($), 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 endorsements . PRODUCER 603-382-9211 NAM EA Sharon J.Tonal_ _ THE JOSEPH S.HILLS AGENCY INC 603-382-3387 Pin"/c"Nt�603-382-9211 ac No:603-382-3387 129 MAIN STREET,PO BOX 300 PLAISTOW,NH 03865-0300 E-MAIL sharon@hillsinsurance.com INSURERS AFFORDING COVERAGE NAIL S INSURER A:Main Street America Assurance 29939 INSURED Bradley Powers,Jr.dba - INSURER B: Brad Powers Construction INSURER C: 22 Wyman's Landing Danville, NH 03819 INSURER D; INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 13-004 REVISION NUMBER: 001 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 RE=DUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR IN=.AGDl POLICY NUMBER MMID�/YYYY MM/DDNYYY EFF FOUCV110 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY MPB9290S 02/04/13 02/04114 PREMISES(Eq o£curranco s 500,00 CLAIMS-MADE FX—I OCCUR MED EXP(Any one person) $ 10,00 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMHOP AGG $ 2,000,00 POLICYFXPRO IRIT F7 LOC $ AUTOMOBILE LIABILITY COMBINED IN LE I. o cccidant $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per occidonq $ NON-OWNED PROP AMA $ HIRED AUTOS AUTOS J,Perar�cJ�,4D11 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE, AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATION- WC STATU- I IOTH- AND EMPLOYERS'LIABILITY Y/N _-„LO.RY-LIMI.T.S_1R- ANY PROPRIETORIPARTNER/EXECU'T'IVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED7 NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If Yea,tleecrlDe under DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Carpentry residential Job: 45 Bridges Lane CERTIFICATE HOLDER CANCELLATION NOAN001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector 1600 Osgood St Blg 20 Ste 2-36 AUTHORIZED REPRESENTATIVE N.Andover,MA 01845 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The C'oynmonwealth of Massachusetts Department of Industrial Accidents ' Office of inpestigaii0la 1 Congress Street,Sidie 100 Boston,MA 02114-2017 wiiny rnass.gov/dia Workers'Compensation Insurance Affidavit: Builders/lContractors/Electricians/PIumbers AlppIicant Information Please Print Ledbly Name(BusinesslOrgm&Ation/Individual): A 6 D PO w e-rr Address: oL ! IogNS ANd/N City/State/Zip: D-3N vide RH- 03V 9 Phone#: ly0 3 - &R2 5--+7 9('40 Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ I aux a general contractor and I egtployees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.R11 am a sole proprietor or partner- listed on the attached sheet 7. RIte-modeling These sub-contractors have ship and have no employees 8. E]Demolition working for me in any capacity. employees and have workers' 9 Buildia addition [No workers'comp. insurance comp.insurance# ❑ g required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions ❑ g ❑ g ]? myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑ Other Comp.insurance required] *Any applicant that checks box J 1 mast 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 contactors must submit a new affidavit indicating such. tContractors that check Us box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'connpensation insurance for my ennployees. Below is thepolicy andjob site infornnadou. Insurance CompanyName- Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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. I do hereby ce7WA under the and enalties o e finny that the in orntion provided above is true and correcx Si at3tree _ ate 7 y'F lP Official use only. Do not ipnzte in this area,to be completed by city or torp)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#' 27, -30" --- , 27 ;� 30 -2t- r f -18 f-78 312" -21 21 ii 1 %i i I -- NJ - 3T N t ! Legend 0: - L. __ ,�2S 2 I_Y /4-�_Zg. Pl Y� r4•! 7 30 :,� 1_ !0 3 d i 1: UT-308724 �``.�� -:r-„ ._, a "t: 2: F-3X96 36REF-2 LY r4-L 1 2I` 3: W3615X24 r# 4: 818L •, 5: 6D303 BT9 bt ' 8:� 7: OFS OFSBLS3645W5 ! - j 8. W1833 3 6 9: W2133R 10: WLS2433R W3016 12: OD183 217 13: BPOS06 14: BF-3X34 37 y .. 4, i 15: BS33 1 16: BF-3X34 17: 13GCD18 18: W1233L m i 111"`••• ;» 19: W1233R 20: W3333 Q r• �i Cn 21: W933L � < 36 y 22: OV3084D 90 V w �.`.._7_--__I_'.r•.- o;` 23: 830 ( ) 77 Q t" = 2.4: F-3X96 k 3 ! \Ji t W 25. WMC-303312 -. os 26: UT-218712L tt M ! cvV cul -`• , --`- 1, 27: UT-218712R El rLi u j 28: F-3X96 29: X12 F-3X 30: F-3X96 tpI ! ? 31: VV3033 32: PNL-4834 KI:non Uo6igned for Mike and Janet Pox a � ca t I 33: PNL-4834 45 3ridges Lane ��^ "I` m N) A-B P- 2 1 EQaj,IW _ _R 75 14,3 -+ of N — �-- - '�--- 34: 0827X12 North Andover,hi.A 07845 4 I 35: 0827X12 978-7943895 WE 20 E 3 �- 36: VAL-5805-S•100 cau 37: VAL-5905-5.100 --- Manufacturer: DoWils Cabinotry Material` Maplei Finish: Autumn Cherry --24 }.,.__ ,__.... _. 72< Doors:. : 6206 NR Maplo Shaker Edge tt6 w/soft close hinges A " Drawer.:. 'Solid woad dovetailed box full extension glide s ,---_.__ :. ...-..-96 H• ..._._._.._..._.,- _._--._.._..1 ,35_•, _ -_ 1421 ,. I -234" all frame&panel drawer heads Overlay: 'Full overlay= / _ _..___... ._. ......_.,�i ,._. Box Construction: All plywood cons ruction 27'- y--- -- 66-a _.- ------- I '.'. ._ -59'_- - ,a�----42<•. -- F r98 ... -' ' Molding: Please see detailed drawing _ 12 24 ----' Designer: Rocco Siman Cyr Kitchen and Bath associate Customar has rcvrewed and approved design: i All dimensions_size designations LTJ This is an original design and must Designed: 6/11/2013 given are subject to verification on TECHNOLOGIES not be released or copied unless Printed: 6/15/2013 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. FoxDewils l 17-87H-312339 All Drawing#: 1No Scale.