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HomeMy WebLinkAboutBuilding Permit #43 - 505 FOREST STREET 7/8/2010 BUILDING PERMIT of p°RTy q TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: !� Date Received 0— C U CHl1 Date Issued: IMPORTANT:Applicant must complete all items on this page ,* i va " m,z= a $�,y •`fir S r+-.—. ,brP +r'..�+vw.z+-i' .'' ^.Ea .x^ - ^•n .si.�a",tL°T * �LOCAVI i � #� # x -?�._ i= iy,, s Lm rr. y,r r 3 'n- S!,Yk"T � PROPER47YW+NERC . * y „srwx~ �� r' �# i% 3r,'. r c. xe ra �`,e c':ri ann L .+nc .+ '�.> tNw— .. .. '^' A'u _ ,'s�` m*`c°`+"AFF+ .� /PARCEL "� .:ZONI.NGDISTRICT� "�' `�x 210 M - Histonc~District . � >.�` ;�,�� • � t� � �'� �����'� � ��IVlachineShop. 0 Ilage� yes`��F�rio� ""x TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial e�air,replacemen Assessory Bldg Others: Demolition Other a�Septic��''�Well f _ 1 , xkr . tet mak.:t' DESCRIPTION OF WORK TO BE PREFORMED: t Cti's S7 PV7-("A776 A Identification Please Type or Print Clearly) OWNER: Name: Phone: 8 S a -?C?Q Address: 90 �8�"C� �' `Ib��R-s QA7-Qe-A2-s "'dc's' Y.+�`,E 4 v s `'. ." s 4 v, xs` 3 -7,Q4'CONTMRACTOR` Name �� ' .ea� , Phone - y S Cwt 7 Addr+�ess �sty7 u` F- � '�+w.>r .t rt'S';4 ^,x '•ts 4`.s a ':Y.. c t M^ EA +h.'++-y.k�' � +rte»' tf_ ^a. n r R '.r'q« 't, a ''�iz'c• a£.'� �F jSupervisorCons ru5cUQ-n L c�ens�e' � ,�c51 �?1 , �E5.,15 rEJ�` 4�. M~'�;vYf`� Y'4.T` ;'Sp.�A � ,".•. �� ��� .}�': I �1.'3'��^T..�3"�11�'+�� ,g iR+Sr�,'�fiSw •gt,.�r"'`,p -'4.t`'1+ t k, .p" 3�t.C.0 g w i +CA4 'y 3 �+ ' �"'�r..... ,.-�� Home llrn roue s r ent.License �� xi� E=x rDate �'� 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: $ 14,060 FEE: $ Check No.: D� � Receipt-No.: 0 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund �j Location No. Date �aRTM TOWN OF NORTH ANDOVER OrC°,/`p° .•,BOOR 1e ' Certificate of Occupancy $ a Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Coeck # a 230 : 4 Building Inspector Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tannin g/MassageBody Art Swimming Pools Well Tobacco Sales Food Packaging/Sales r 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 Signature COMMENTS d 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 4 Osgood Street -Xo L`Eo"ic.7ra,et'�e}Ddsem,e:--,p,.aar. R mea.'riin t gtuermefpd�aD:'uteme atIa �1REDEPMENeu24 �SBe ." srF ---.G ` - s,, �• ,fir�'#� 4�J+' ��'�,i.�i 1.,,�.,.. 'fie�9 "�'�ixa� - m" *5. r� ,n 's'Y°�",-; .+"m' �- �'ss"�.-n,X,§�", ."�'`w' "x'.+ � .. E�:s..,a.4. `Y�.�-#a �`w .:. ^s r,- �-`[ ,� w�'. �+a y,tI'a- z",t�.,s '' ,7 .�- +. . ar„'� .+•w.,C -.' lig a�•n i 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 Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ ' Building Permit Application ❑ .Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of. Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo.Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) I ❑ 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 i 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 1 Doc:Building Permit Revised 2008 I 11 w"1 _ O M r O a IV W Office of Consumer Affairs and 14usiness Regulation . 10 Park Plaza - Suite 5170 Boston Massac.-lasetts 02116 Home Improvement Csot�r, ctor Registration . Registration: 159567 Type: Private Corporation Expiration: 5/8/2012 Trt/ 296539 BUILT SOLID HOMES, INC. KENNETH MORGAN 75 INDIAN ROCK RD. WINDHAM, NH 03087 ?; .,, _;~' Update Address and return card.Mark reason for change. -- Address 0 Renewal [-] Employment ❑ Lost Card DPS-CA1 0 50M-04/04-G101216 2\ Gfot/ °�` "'�Q�� License or registration valid for individul use'only 4 Office onsuinerAA fairs&R siness Regulation g HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ---`-59567 Type: Office of Consumer Affairs and Business Regulation Expiration: .5%8/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 BSOLID KENNETH MORGAN 75 INDIAN ROCK WINDHAM,NH 03087: Undersecretary Not valid without signature "a ., r Jul 08 10 12: 3Gp p, 2 r Y. Terms>tu>d.Cor>,ditioris - f �'� . '!'f�iss!pripd cstitp'6ie/contract ha;ont�o contCoef omcs.Inc.{bno.5n�at.tArttr`t_xoel t+ndJlr`:fsomeovsner,(n t,;, :'o3Ycptln�}; t `• the Gqn)}acr mi�rt ha signed bp�th�, vriet.ThiS.Ltintruct Is'bintUnif woes,spou>es iu pope.ity w owricrs,he(rx xxecurors atlminlstrptgis;successors and;risslitris of buyers r Scone of.tro driy_e O;de`/Qrder of d(icurnentarioit WoYk to.be eumpleted is descrfbccl in rhis.eiumate.It li c[ut!'esih¢descriptions on tiiisastimote,.opliot�S,U{iUrativs':punrh fis!,nd adden4h)aRaCh61Anctttp0 conflict.,Incliuioiis descjtied on thls:ei0m ise'uid nttached:iiildrndurit'{rroccxtls over.*is and spesinkations.Arty extra uifrb and eliar ges to 5¢mnde.not stated lit to•uract w(II he an'ewrr;coir incl,sttall be.tilled ncfusnge ordei,Change:cirrlCrs nic.P-N la11•i;tiiv3 s(Vnedfdr;u•time'o�changg N(':Ytnfi'tb'Ii fry'stato and kscal codas.. Reau.frzmertts tYf Vu(it9c fSt ies� - - ;Contractor*ig not assume respopi)b(liry;Soc pceaxktyiy wde.vtislonurIs of)twdegnaie:physlcuhsisiictural..;.mectrmdcal oi•clewicaVcond)rltcns,Any chi alp required by.lxilillc.fwc}y' ::. Wild!j iiivfrtx to'Dr w!l)t.skull ba n.'NL or8es and tiP;`W for owner. y. r ^�' ... t kw by' �1avn1sq="Mil tif Pav(neptd r A 10sf,:deavid sipnad'tirntrxi bha)uired(1.fn move:prvj@t1 fcuWai'tl;sclwdule'mwk cmd'arden matti)al5 M1r:tS Is due o!,N work start date.PtGjcct that "I two weefrt br Icss.-final PAvrrKsn i<due in futf:upon comrkticm.Projects fa�2er tissn g weeks will have payrnerti schedulc.dpachetL Daytnesp qit projedc'ere due lllsorr Iryoite and P!i'ef poyments are title lipm slyi+ed punch fent,Punch,lisis wlll,W...complered'after.tiholptyafeni:(S,receivd�tb ei:uirc,prnJt�t,ls ttnollrkd':opi!closed,,Any herw-dial occur of er the,punch list is*Wrnp(e,etl' bacomesama7rantyhemSO$ Watritny)If aKettt arc not male:Dn ti mo. : n . ao,srsV swlt vtadl.of irwok(ts ure puid Its ful(;;:: . y" A]1 SPECIA':OPMRPS PEQU,F2E A-1669 NON.gERl121pAlSLE PAYMP NY 69-MATEPjAL .. Teinlinatiorl of Contract f7ds ccmfrntt u n be;tamtlntu xt vo(tltln.3':'buslne s.dpys of itu eption.[t annll fobs.}u�seaned.beTonc or Gtirbiq the 3¢uy ptaW4 at the rexivast'of the tw+ner and after Pro(ect is x21A motion.connad cannot t�canceled yclfhoimpinitty.CUK4ilL10111peirnitq befoie acnwf.viiirk has suited due;iei Cline and ctinsidcna ticih of lilanniitg ano:schedul(ng,Is UWis,tif ' , .,deposit roc�Teed.After.start of warir,conce]le4on of.contract by;dwtier gr.c`ontrocitrrpi Any time,2onstiwtgpiiymenrof unpaid'items at unto''of mnce[Wiion Unpaid items tire dme.:' and mnitrInls io the project,Time being the c4ul4lik t of$J%6O per dgy.rnattrlpls being cess(plus Joxr.', 0. S:ompleticin of-Work �- - -.. - An work'xmpTct)on is of:ih"e-essersu_+ftid'trocordfng to a6.ddendwii lir time,fgame lnclnded not:irictnilud to iietial shorio;lc..ezces3lVe viceatheh;ho11da.,filed ottyiuher unfcirc�eun ,..... un6earabit condirwn ltiii.map:txcur,Aray:Fttainge orders may constitute additional arnt `un a C ntrnctor.'is W carry,danergl-(ability an J workers cortijrertsg . tion throttefiow seopt :of'worle: •Cc�rnmonkititfon •`' � • •" As rxvJ6 confuse;tiraages e Gf gorG oa treF astsQ cp+nMuiticatt ate nny sub conlratlGii'4nly thcou jh cogrr.actw'Owner dtxa not hime,tuar..onwol gvcr-const LidiGn : ocC{ures oitechnt Ul'A�W.tbia,nrc the G¢YMCaC10rS.. .'..�.'•. J:.�'..` 9 (Y .o prea:. : sremc>'saJ/AretinfConstriicr�> i _o �sf�. (.ontmcror.is aespondb(e for rep oval of any mnstrumloti debrls bio4ht on 67 scope+qf work,ctnlrss otheor!se t>oted:.lx'ork arpe;ls fah In.a btoo!n•'svfejjii cundi!Idn.(:orttrscror Is ... m...- -hot res nsiblo So;:ducvt mt )or dire _".'Contractor will:elle ieenoru ble care dMir- Ru - pzts(frt;ss and will gadnt out meas otkxiristructlun:odd is riot:responsltile for any,dama;,>r m prsriDnul prgpeny�noorir.'sil;ftnnitute:fownx,.liushes and'shnttxs,flowers,walkways,dr.tvewaps etc-r,`oneracturs'atul-worfrt}ian canndt'be tesponsybte for dtaiing doors-and 01ca'fi3r children and aritmufs If huznrciiicis mntrrJals.arc diseGvcred:The crwnt r 1S'itspuns!btc:fuc rtariwii(and handling of Ji alt rlul bp'<jur:llfied;sLLixtNuracturs uric)sfusTfbc cutisideiod o..: changed •'::r - S21res iii .nurfntt Ctinstrutdeii,; : CcmtrSccots;;iesptmsibilitydufing.comimcdoli7s to kcCa..joWle t40ri of intrle ofs aM debris.MaleilafsandSKUCtttrQ AtC'!O bc-5ecircd a9(iTSliclsin,ttdtnsal ccCathCC 3ci(vities' :Ab,;ormsl:mearhitr-sctivides ancl'natura(disinters inehidinV bur.not limited.ro me*vawino.rolm lightefitng.eartflgetc;'�are not:tie::cspauil';niy Of rhe crn[rnetor,i%irtp damage sustuinec]•durtng,yicoiher Wldware tlie'resryoris[bll(ty of tlie`owtiec;...' 'r l�'oironty a leers s:rueturol work and iinl>ropeil➢Into U m4e lis;xilq up-icS 'geirt from compliiivrt of(ivJ®ct Some:nt x tsif niril Nrtxlticis hate tiieii'smn rift nufacturcis'' :. ,ukhrwnty uticltirc nut,i wcrcxl utitttr thu..wt imntpr.CviorGd ircnis tK>NO JNG6UllJ GraaJoccl_3syvrull vr,.cyttcrrtr;yrywtt sell ws pcf r iryg of t.�.psng; n.n e. ,rodtnyi 6rpcupg;.` ant.64sring of.bu)lding dit).Ials andltimautxl cal iwd by stirh items listed.,�hrtuitfe from:excaslvc w6athei and excessFve'riiih of dp to B lritdnevormom within a:Q4"hour tliid. _ ;1tnY rxxaonaric.mY.Damn+pi. it wnrnrnty teem, ..Jul 08 10 12: 33p p. 2 i`. : is ertns:rind:Corid _ u ons .... ...: ]tiis:tigntd¢stimnte/onrpc (xtanrs'p - Said'Homes,..Inc, w: '=� .•.yam.: tp..:homemper. In cp :gredn :`tteanmslgxed t`hr,e Ptyui r.lhiP. ctntrrtct is:b[Ming upoti,slruL&s or property w own irs,heirs,ticutom adminlstrtli6rs'Stn•cesslirs nnd'assigns of.btlers _ 5'cotiii of work> harib Or Gsl�Iaier of dpCTtsrnt"tuaiYtin ;:� _ - _ - "V7odr iobi:rompkf A Is descrl6m In lftiv_e3titnute.Ic l'neludes the descriptions on this estimait,pplitnts ujigrncles:.piuich IN Kiril addem u altocilAii ln.cuse of ctinAiu inetusiviis des rjlied orth[s�si{mnte raid attached.iiddendani jxoceetis•dver plain arid specrfkations.Ai!Y,extia want and dranges-txi ba made not staled Irl t[tLt contract w111 6cexon cost arld.shntl be,.mlled a cfuttidc ord:ri,:Chariyc,ordero wt`:Ip be pnld..dnd signAd'ttir at rim's iif change:A71:w srtt t6 b._hy'stgt i and lirc;i'wdcs,:. ReauirerrtetttS of 1hiGlft:(3odS;'' .. - E antracwrwif)no;as>ume?espy'sibillty'cit vnaexialtig'code vibktiotu o[t'nude'l"'A liysiceil slructural.cmecfwni rol or tlertrieaS'condinc rsi:Arty cl orytea regtt[rcd hy,ytil;Tlt hotly;;.`' builtlitrq iiisixxior.:iat untlty r;futtl be a Oibnge oidcr and bu.pfc]for by.vanar. ��49S1fsSli3tIII11FSlS afS A 110.9.depr:slt.and styned';crx vaa ts'.tequlred to:move prcijcct PorWard;'sdteJule'worh nntl ordu m figtfals:1G1 fs due urs writ scan date..Projccis that pre two r trsor tcssi final payment is:duC in EuQ,upon c(MfiCtetfon.Prpleces lan`¢t':than R wetitywiq 1slive laoytnentschtxlule pdacfied Poymern5 ilii:protects aie due aper Invoice and fltipl,p?fv»rnti are due. .ulrctn signed pancl'i;:fist.Pnncli9bcater filltrf.;papneht is received to en5uie;.Nrc+Jc�t,ic hiwlisecl:riiti9 cfucixl:Anq items:that ccctirafmr the:puiuh list:.ii comPteted [ucomes a w.urartty item (Sce WJitrtinty)If payriicnts.rre'uot nxide:tin note cos tatcror reserves tfte:rSQht to op.vvorit utitil.alf iovoic8 me paid.in Sult.. ALL SPECIIiI nRl? 12b REQ1IfRE A-1Opti�NON;:�fl1[1AAJ3LE PA-MENT,OIV,MAMiAL I erltrutdi(on of Contrflt:f: .. ;;;:.. .. .. :rhes tcntrdet cnn h¢:tennbtauxl uilfiin:3-lailsiriass.iiu of lnertpiton If-small'Jo6sa esiarred hd'oreor tiitrinq the 3 clay p@rioif mt the repus3t u[the»vritr pnttalter c:> 'ftit Is 4t iii '{ i o mutl�n.coptraci,cnnnot be..eancefCtl,.y jthotn enalry.Cant iaticn pertpity Ixfora acnral:morte has started due t6 ame nnd wrssideragon of pladr%Ih j anil;schedu[ing is 100%of depasit reeel;<k After sutrt of work canaellml6n of conrrpct by oiviier ur wntractor Ar any time,eaastiuttes:pafTnent Oy unpaidliems at dm 6f enoceUMion.lin'Old ken's arc time•• and ritniellah tt)�roptct,iitnabetng tfia etiutwilentof�..i2OD per day>ritateriafs lxing ccist:plus t!0s4'.: �ompfenon of WorTz :' - , All work wropletiixi N of,th'c-'essuneG er:d accocdrng io g6piddencluni or umr fiaiirodncltided na•ipclridtxf rnaicnd siwrraum..exces ivi weatlu5r;hafMn}sand atsyistfior'unitnreen un6eornble cunditlop that may pecur,Any:,chnitge olden tney ronstlwto additional dine on a.pTPjeet. _ noe nstz Ciinlniclor is to carty.gsyierel liability un(t:worfeers.eam»ensad on:thruughout scopa:ofwart•:;: .•Communicaric n As nat.to'.catdusc:r}uinges and'scope df work awr er siutl!co)to nwniGt2 to arty sabcomnictciison ly thrdugn curviaatu:Owner docs not liaw uny;ccaurctl ctvrr i atutrdcnnn prdcat{urts araechnlqucs irs xheselire the ctxritactors.retpbnvbiQiy.` 7ebtrs`ernoval%Art;tistr.a �MnPa."'*'I* .;,):' , . � - -•' . t.:vntractorJsaespongi `ior removal of any:eonstruaiSn debris-brought ori:by scopeio 'work.unless othefWise trotelt::fY orit atop is lek into broom, condition.Comrscior Is ; :not re pottstble for.vuantminq or dusunu.C antracttir will race xeasonnhle ttre'd%jriiiq pray v*and will r;olnt out mew al cohstructi and Is.nut responsible Our atm dame to_ perst>nnf prapeny.flooring.furnilti?e.I rsns(iytsties and'ehritbs,Towers,wnlLWays.drivdlvays etc.Conir tctors anti woi'Fmren canrf ir''be'resprstn761o,&7r cftisfnq dr;ors Arai awtes for ctt)Idmrt and animals.if hasardbus tnatCs tils'are d- red.dm.owner a rrsponsiblc,for rt7nwal aunt haitdlind of ttieicMal by'cjuutiried:U66 T'S and St all be car ed R s)'>nst i lily.I)etrina Constrticdon Cnniiuctats"..reip�tsibility during construciiori;is.to keen:jobsitc.cicgn of mattirmb and defiris,btaictiols anJ:i riicu rc rice io be ww' icd as.ta-us n,norrdal Bather naividcs. 'Abnormal moaiher;naj t'i'cs apd:nnturnl disiWars Inchiding bui iiot Rmit A.to exct siva wind.rliln.lighrGiliv.'enrtitgiibla's;etc':are not iltt}:icsfj"il iflty trf thrciinitactor:.Arry dnmpRe aisttiined dodge:�enihei 3ctivitie.,are th6 resppnsibitiry of ihe.'omher, ..' Warranty 17turanty aiders strucluial,lottrk andingsrci'*'Ty Installed materia 5 only ufi.to, yre+tr froth completion of project;Some inaterlilsmarid pvdiicis'6ve Iiiei 'own tnariufaccurcrs ..u`prwniy arid arc nvi;i:uvt•.n:u`urulnr rhln.wurruntp.;S:o ,rc:{I ivaris 1)0 NO INCI.U4Y.:Crackccl'isrywittl ur,v-'CnCrctc,,citywuU.kra�s popFir:g'orn.w,ct+P^ny.swcDliiy,'fn<il. y nciin arid-twisting of..builtl'urg rfi tierfpls aitl:ilatnagul ctrised by'9iich itervi,6 isiod.l)iiinalx Srurro:cacess(ve wurdttei and excesstiv,min of,Oi ,to 2.intltc'ixmure.within a 24 hour•perlci j. Airy pirsortal`itcrn,damaged. :ppq wprruntjr juin. ,'.';:'' ,..' �I h O • O O 1' N - Office of Consumer Affairs and 11usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement .�:ontractor Registration . Registration: 159567 Type: Private Corporation Expiration: 5/8/2012 Tr# 296539 BUILT SOLID HOMES, INC. KENNETH MORGAN =- ' 75 INDIAN ROCK RD. : ., .:: --- -- ---- ----- WINDHAM, NH 03087 IT l> tUpdate Address and return card.Marts reason for change. L] Address [-� Renewal [—] Employment Lost Card DPS-CAI 0 SOM-04/04-G101216 Office'of Consumer A0f�fai s �R�sines�sRegulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:,;_=159567 Type: Office of Consumer Affairs and Business Regulation r Expiration: 5/8120.12 Private Corporation 10 Park Plaza-Suite 5170 :::::: :::..... : Boston,MA 02116 B' t SOLID KENNETH MORGAN,- i% 75 INDIAN ROCK Rp, WINDHAM, NH 03087:'::-.`.- ?'.;`; Undersecretary Not valid without signature r The r✓'o►nnionweizlth of Massachusetts Department o f Industrial Accidents Office ofrnvestigations ..600 Washington Street Boston, MDQ 62111 Workers' Am Comaeonnsation IWWw-Mgs&-bov/&a Iicantmnsurance Aa it: Builders /Contractors/Electricians/Plumbers Please Print Legibly Name (Business/Organizationfi dividual): Address: 7s City/State/Zip: W u�-� AJ cf' Casa �( Phone#: b c :� -Cl4o-y a Are you an employer? Check thea appropriate Cil PP priate boz: I- • I am a employer with 4. ❑ 1 am a o Type of proj7ed),,, employees(full and/or pe) * have hired a contractor and I the sub-contractors d ❑Neu c 2-❑ I am'a sole proprietor or partner- listed on the attached sheet r ?• ❑Remo ship and have no employees These subcontractors have working for me in any capacity. workers' g• ❑Demol No workers' comp. insurance 5 pomp,insurance. 9• ❑ We are a corporation and its ❑Buildirequired] officershave exercise 10. Ele3. I d their ❑ ctn❑ am a ho m eowner doing all worknght of eK � Myself [No workers' comp. right c. htIS I =mption per MGL 11.❑Plumbing repairs or additions insurance required.] t employees4)�and we have no [No workers 1 ❑Roof repairs COMA insur=ce required.] 13•❑ Other -ny a*�QIi^="*that h box: m+st s?so Fu:Qet the seciiea c_eot.•°^ox:rb . ------------ +Homeowners who submit this affidavit indicating they ere dcing aU•aork =ar ire o 'CQmY r s'^M YVyc�Y� n. Contractors that her"tl s bay==attached an additionai sheet rh,, �a � °ntside contizctois i ., yQ- ubmit a new affidavit indicating such. the name of the sub-contractors and their workers'.co I am an employer that is proi,��g workers'compensaiion insurance for my e l ees. Be � pQ���� information. mP oY low is the policy and job site Insurance Company Name: ?CJ, C Policy 4 or Self-ins:Lic. a a 3 � 3 Expiration Date: /L r(/ Sob Site Address:�s �e�5 Attach a copy of the workers' compensation policy declaration as City/State/Z' X) Failure to secure coverage as required under Section? page(showing,he policy number-and expiration date). fine up to$1,500.00 and/or one-year imprisonment,aswell �MG�c. 152 can lead to the imposition of criminal Of up to $250.00 a da a Penalties in the form of a STOP WORK ORDER pities of i Y against the violator. Be advised that a co and a fine Investigations of the DIA for insurance coverage verification of statement may be forwarded to the,Office of I do hereby certify under the pains and penalties of perjury th4rr dw in or f 'nation.provided above is true and correct Siffiature: Phone Official use only. Do not write in this area, to be completed b,c , J itj or town official City or Town: Issuing Authority(circle one): Pernait/l icense# 1: Board of Health 2.Buildin;Department 3. Citv/ Town6. OOther Clerk 4.Electrical Inspector S.Plumbiab Inspector Contact Person: Phone r: Information, an- d Instructions Massachusetts General Laws chapter 152 requires all employs to provide worlo'rs'compensation for their employees. Pursuant to this statute-,an employee is defined as"...every pt✓rson 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 t1ae legal representatives of a deceased emplover, or the receiver or trustee of an individuaL partnership, association ox-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 mainte:mziice,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not beicause 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.perfo�ance of public work un-t:g acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please HE out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and if necessary,supply sub-contractors) name(s), address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'comp ration 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 stare to sig and date the affidaviL The affidavit should be mt'e;rnu-,,to the orty ar town that the apulicauon for the pn-mea t.or license L4 being reaues*.ed,not We Depa, —T.of Industrial Accidents.. Should you have any questions regardi�.-,the law or if you are m-'K zire to obtain a workers' compensation policy,please call the Department at the nnmbe:T 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,nee 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 ofInvestigations 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.fagnumbez;__.. The Commonw=la of Massachusetts. Degartrnent of industrial Accidents Office of Inrestibatlons 640 WashinP-Earn Strect Boston,MA 02 111 Tel. # 617-72.7-4940 ext 406 or 1-8 77-MA9SAFE Fax#1617-72,7-7149 Revised�-26-0� vrvrr.mass..s;ov/dia From:Pam Guerrette FaxID:Santo Insurance Page t of 1 Date:7f72010 10:54 AM Page:1 of 1 CPRCERTIFICATE OF LIABILITY INSURANCE FDFATE(MMJDDNYYY) OP ID PG 07/07/10 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. ,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 Rau of such endorsement(s). PRODUCER NAMEPHONE ---TFAX: Planright Insurance-Salem (AJC,No,Ext): (AJC,No): 224 Main Street Suite C ADDRESS: Salem NH 03079 CUSTOMERID*. BUILT-1 Phone:603-912-5646 Fax:603-912-5647 INSURER(S)AFFORDING COVERAGE MAIC R INSURED INSURER A: MM Insurance 15997 Built Solid Homes Inc INSURER B: Pacific Employers Ins Co Attn: Kenneth Morgan 75 Indian Rock Road INSURER C: Windham NH 03087 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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. MoK em- LTR TYPE OF INSURANCE SSR POLICY NUMBER (MMIDDJYYYY) (MMIDDJYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY SC10973311 06/30/10 06/30/11 PREMISES(Esoccurrence) $250000 CLAIMS MADE aX OCCUR MED EXP(Any one person) $5000 PERSONAL&ADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2000000 X POLICY JEECCT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ lOOOOOO (Es accident) ANY AUTO KA10973311 06/30j10 06j30j11 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WC RKERSCOMPENSATION C46297313 05/16/10 05/16/11 XX AND EMPLOYERS'LIABILITY Y J N TORY LIMITS ER VV ANY PROPRIETOR/PARTWIRJEXECUTIVE JA E.L.EACH ACCIDENT $1000000 OFFICER/MEMBER EXCLUDED? Y❑ (Mandatory In NH) E.L.DISEASE-F1AEMPLOYEE $ 1000000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1000000 DESCRIPTION OF OPERATIONS f LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,M more space is required) CARPENTRY RES. (NOT ROOFING CONTRACTOR) WC: 3A N MA / Kenneth Morgan has elected to be excluded from coverage. Job: 505 forest St. , No Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jack Rayner 901 Ferncroft Tower James A Santo anvers MA 01923 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ORTH F ' Town of 0 , Andover . No. W.. W. o43 A K E O over, Mass., COCMICMEWICK V / A � SS p'Pat�C� v ` BOARD OF HEALTH PERMI,,T T D Food/Kitchen Septic System BUILDING INSPECTOR BUI THIS CERTIFIES THAT....... ............... ... ��ti. !! .......................... ...................................... - " ' Foundation has permission to erect........................................ buildings on .........Sar.........��. ' . ...a Rough iv�I� Chimney to be occupied as.................... ... ........ ...( .......IcO1V,.� ...... .. . .. . . . . . . . .. . . . . .. . . . .. . . . . ._ provided that the person accepting to permit shall in every respe conform to the terms of the application on file in Final 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 16V PERMIT EXPIRES_ IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU O TS Rough ................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Oca cpy Building GAS INSPECTOR 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. SEE REVERSE SIDE j Smoke Det. C j *=. N1uss.tchusett, - WItit.rtinO e ai t Public ti tt'et) r Board of Build ii Rc-�ul.ttion, and St ut(tuil� Via! Construction.Supervisor License ' s License: CS 101271 Restricted to: 00 KENNETH MORG) 26 MOOSE HOLLOW.-RD LITCHFIELD, NH 03052 ir Expiration: 6/15/2012 ( unmi, i wrr Tr#: 101271 d e r f 07/07/2010 12:44 9783528054 ESSEX COLUMN PAGE 01 Jul 07 10 09s40a=Tf IT © II 75 how Rock Rd Wm& m NH 03087 Date ErAmate# • Haat l� 7/ zoio 20104 Name I Address 18&Rayner 901 Fancraft t Tower DAnveas Ma 01923 Iters Description Cost Tonal siding Install new vinyl sidwg oar cu*m siding,AMux 90 aq•"Color 14,000.00 14,000.00 White Imtall 318 Fanfold inaalatian uudmeat aiding. 4 Adm of tRmam fay Ross of homr- Vinyl b1or,b and vents wbut" amble White aflu mm mu mesal Vmq on tom around fascia Wbade vented sem wbem applicabk 5esvim Address: -03 Faacat St N Andover MA 01845 Sign Web Site Signature RU olid a+ww olidTtomescoin