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HomeMy WebLinkAboutBuilding Permit #205-2017 - 530 MAIN STREET 8/29/2016 AAI w4 10 R T!i BUILDING PERMIT oF�p&OR qti TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#. ` l Date Received Q SSACHU`-'� Date Issued:08 IM 6RTANT:Applicant must complete all items on this page LOCATION 0 1D MCI n_ _'S_L Print PROPERTY OWNER M CL,9 e Y?a A 4 Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg A Others: ❑ Demolition ❑ Other ❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed' District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: IsY)�'► Identification- Please Type or Print Clearly OWNER: Name: /YI r/ha-,/ ✓I dl o4 Phone: Address: !0 o Mo7tNA S i Contractor Name: . . - Peter !��F 2 Eat ate p1trec" Address: - _ Plaistow, N.H. 03865 978-407-7638 / Supervisor's Construction License: /oG o 1 Exp. Date: Home, Improvement License:_ ��01.71 Exp. Date: 2 A - /t.___ 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: $ ©d0.0 V FEE: $ �'� Check No.: - Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to t4 guaranty fund gnature of Age.nt/Owner Signature of contractor0id - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimmning 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 Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster 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 NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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/Cross Section/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 a 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:Building Permit Revised 2014 NORTH Town of t 6 ndover Y41L soh ver, Mass, 09 Z ZED/6 [OC NICNIWKK S U BOARD OF HEALTH Food/Kitchen PERMIT. T D Septic System t THIS CERTIFIES THAT .... .... .��ir�1!� .`........ ..................:................................ BUILDING INSPECTOR has permission to erect buildings on Foundation Rough to be occupied q.r....PV.V... .................. 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 CONS TIO Ira Rough Service . . .. . ... ...... ................ Fina ..... ... B DING I SPECTOR 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. © 035 Federal ID#OS4405629 RISE Engineering RI Contractor Registration No 8186 MA Contractor Registration No 120979 RI S E A division ofThieisch Engineering; CT Contractor Regtstratlon No 620120 ENGINEERING 60ShasvmutRaad,Canton,MA02021 �'+►/�pti4ppraT 339-502-5197 FAX339 502-6345 CONRC TAT 1 Page 9 PROGRAM TM cotfMcT is envmo mm S9nvEEN ROE CMA-HES EUGINEERING AND THE CUSTOMER FOR WORK AS OESCRtaED GM.OIN CUSTOUER PHONE DATE CLIENTS WORK ORDER Michael Nolan (978)239-0639 08/16/201 28 28602 SOW=STREET BLLMSTREET Lcz 530 Main Street 530 Main.Street j� v ctit— SERVICE CITY,STATE,ZIP MING CITY,STATE.ZIP Noah Andover,MA 01845 North Andover,MA 01845 1 9 2016 JOE DESCRIPTION uu AIR SEALING:Provide labor and materials to seal areas of y-our home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can include cauft,.foams and other products. Primary areas for sealing include air leakage to aaics,bitst mens.attached garages and other unheated areas(windows are not generally addressed.)This will requite(12) working hours.A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety of theindoor air quality. 51,020.00 AIR SEALING:Provide labor and materials to install Q-Jon weatherstripping;and s doorsweep to(2)doors)to restrict at leakage. 5+150.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 unfaced fiberglass baits to(218)square feet for damming purposes. 5446.90 ATTIC FLAT:Provide labor and materials to install a 9'gayer of R-32 Class I Cellulose added to(1278)square feet of open attic space. 51.827.54 WHOLE HOUSE FAN:Provide labor and materials to fabricate and install a rigid foam insulating cover for the whole house fan. 520931 ATTIC ACCESS:Provide labor and materials to insulate the back of(1)attic hatch with 2"rigid Thermax board.Weatherstrip the perimeter. 560.00 VENTILATION:Provide labor and materials to install(1)insulated exhaust hose with roof mounted flapper vent to exhaust existing bathroom fan(s). $118.75 VENTILATION:Provide labor and materials to install ventilation chutes in(100)miler bays to maintain air flow. $200.00 INCENTIVE:RISE Engineering will apply all applicable,eligible incentives to this contract. You will only be billed the Net amount_ Currently,for eligible measures,Columbia Gas offers an incentiveof 75°/a,not to exceed$2,000 per calcndarycar,and an incentive of 100°/a for the Air Sealing measures up to 51,020 FOR A LIMITED TIME:Columbia Gas will also offer an additional$100 incentive towards the wcatherization work outlined in this proposal.This special Summer Incentive is available to homeowners who have had their Columbia Gas home energy audit before August 31,2016. A signed proposal for weatherization needs to be submitted by September 9,2016 and work must be completed by September 30,2016. For the safety and health ofynor home's indoor air quality,%vc will be conducting a blower door diagnostic of the available air flow in your i P •y Federal ID 9 05-0405629 RISE Engineering Rl Contractor Registration No 8186 IAA Contractor Registration120979 A di��sion of Thiclsch Engineering CT Contractor Registration NDo 62012020120 RIS ENGINEERING 60 Shawmut Road,Canton,AIA 02021 CONTRACT 339-502-5197 RA339-502-6345 4 Q�N Page 2 PROGRAM THIS CONTRACT TORISE CMA-HES NGINEERIRG AIRl� E0OMER F�OR�WORK AS DESCRIBEDBELOw CUSTOMER PHONE DATE CLIENT IP WORKORDER Michael Nolan (978)239-0639 08!.16/2016 437928 28602 SERVICE STREET Bn1NtG STREET 530 Main Street 530 MainStreet SERVICE CITY.STATE,DP BnIAIG CTTY.STATE,ZIP North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION home both before the Wort;is begun,and after the wcathertzation work is complete.We Will also conduct a full assessment ofthe combustion safety ofyour heating System and water healer.This has a value ofS90 and is at no cost to you. The maximum allowable incentive for all measures,including air scaling,is$3.210 The Permit will be secured by the insulation contractor,at no additional cost—ft is the homeowners responsibility to close out this permit by contacting their municipality at the completion of this work. s $90.00 `J ` t AUI-3 Total: $4,122.40 Program incentive: $3,210.00 Customer Total: $912.40 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Nine Hundred Twelve 8140/100 Dollars $912A0 UPON DPSPECTION AND APPROVAL BY ME ENGINEERING.CUSTOMER AGREESTO RENIT AMOUNT DUE W FULL II EST 1%VALLBECHARGWMONTHLY ON ANY UNPA AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES.RIGHTS OF REM .6 - .AUD CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF TH AfWA K SPACES AUTHORED SICHA •RISE EnpinncAnp TOMER ACCEPTANCE ROTC:THUS CONTRACT MAY DE VATHDRAVIN BY US if NOT EXECUTED YATHIFJ DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT•THE ABOVE PRICES,SPECIFICATIONS AND CONOMONS ARE 30 DAYS SATISFACTORY TO US MID ARE HEREBY ACCEPTED.YOU ARE AUTHORIMO TO DO THE WORK AS SPECIFIED,PAYMENT WILL BE MADE AS OUTLINED ABOVE SII r RISE60 Shawmut Road,Unit 21 Canton,MA 020211339-602-6336 ENGINEERING www.MSEenglneering.com et:;. ,: -.'_•,•*::;ori. OWNER AUTHOR17ATION FORM Michael Nolan (Owner's Name) owner of the property located at: 530 Main Street, North Andover, MA (Property Address) (Property Address) hereby authorize �0 ���1)PQ t' 7�7MSJ/Q (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. form is on y valid with a signed contract. Owner's Signature ��RR nn Date 6110/2016 Preview:Certificates of Insurance �1 ACORV CERTIFICATE OF LIABILITY INSURANCE a�,t o 076"Y' 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 CONTACT NAME: 1AXPHONE Automatic Data Processing Insurance Agency,Inc. Arc No.Est: jac Not 1 Adp Boulevard AOORESS: Roseland,NJ 07068 INSURERS)AFFORDING COVERAGE } HAICR INSURER A: NorGUARD ircwranm Comparry } 31470 INSURED INSURER B: } POLAR BEAR INSULATION CO INC INSURER C: } PO BOX 958 Andover,MA 01810 INSURER D: } INSURER E: } INSURER F, COVERAGES CERTIFICATE NUMBER: 503587 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE INS POLICY POLICY NUMBER MWE)ONYYY MMDJ LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CIAMS•/.iADE r-1 OCCUR PREMISES(En ottunc_nce) S MED EXP(Any one person) S PERSONAL 8 ADV INJURY 5 GENS-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S PC,ICY❑JE O- LOC PRODUCTS.CO.`.iP.'OP AGG OTHER: S AUTOMOBILE LIABILITY SI GL .I I S 'Ea-6dentt ANY AUTO BODILY INJURY(Por person) IS All OWNEDSCHEDULED BOOBY INJURY(ParacdC_rt} S AUTOS AUTOS NON-OWNED LIAMAQt HIRED AUTOS AUTOS IPer acadmq S S UMBRELLA LUIS OCCUR EACH OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S WORKERS COMPENSATION XH• AND EMPLOYERS'LIABILITY STATUTE ER YIN ANY PROPRIETCRIPARTNEWEXECUTIVE A 0FFICEPAlENIBEREXCLUOEO? NIA N POWC772258 01101/2016 01101/2017 E.L'EACHAcaDE1QT 5 1.000.000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 5 11000,000 It yyes.describe under DESCRIPTION OF OPERATIONS be:ow E.L.DISEASE-POLICY LIMIT 5 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sctwduk,may be attached 11morespam is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood st I suite 2035 North Andover,MA 01845 AUTHORIZED REPRESENTATIVE J�l 1 A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD https://adpia.adp.com/icertcf/#/run/preview/503587/900012975 ill AC�® DATE(MlWDD(YYYY) CERTIFICATE OF LIABILITY INSURANCE F6/10/2016 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(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 endorsemen s. PRODUCER CONTACT NAME: Linda BogdanoWicZ Insurance Solutions Corporation PHONE(Atc No,EM, (603)382-4600 1(iXIC NO:(603)382-2034 60 Westville Rd E-MAIL ADDRESS: corn INSURERS AFFORDING COVERAGE NAIC/t Plaistow NR 03865 INSURER A.-Western World INSURED INSURER B Nautilus Insurance Group Polar Bear Insulation Company Inc INSURERC: PO Box 958 INSURER D: INSURER E: Andover MA 01810 [INSURER F: COVERAGES CERTIFICATE NUMBER:CL1632326134 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER M Y M YY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE �OCCUR DAMAGES( RENTED 100,000 PREMISES Ea occurrence) $ NPP8274967 3/24/2016 3/24/2017 MED EXP Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑SEQ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 BEXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 14DED I I RETENTION AN026107 3/24/2016 3/24/2017 $ WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTNE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St, Ste 2032 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Keith Maglia/SJA `- 1 `1��-- @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(901401) Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 102726 Type: DBA l n lEFEEi " ,fix Expiration: 7/2/2018 Tr# 419291 POLAR BEAR INSULATION CO. Vincent LeBlanc i + P.O. BOX 958 ;1 ANDOVER, MA 01810 t Update Address and return card.Mark reason for change. , SCA 1 W 2OM-05111 Address 0 Renewal E] Employment E] Lost Card �e�o»rnronn�enl(f n�'C/��ry31liC/rrse((s Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:._ 102726 Type: Office of Consumer Affairs and Business Regulation Expiration:_ 7/2/2018 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 POLAR BEAR INSULATION CO-: .6- Vincent LeBlanc 51 SO.CANAL ST.#5A M� LAWRENCE,MA 01841 - Undersecretary IV Not valid without signature 1 Massachusetts -'Department of Public Safety S Board of Building Regulations and Standards Construction SupenicurSpeciait} Adnbk License: CSSL-106017 r n; PETER A LEBLANC 2 EAST PINE STREET Plaistow NH 0386-5 Expiration Commissioner ` t 04/28/2018 I I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,JITA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): P01 AR REAR iNSI 11 Ai7r1111 PO BOX 958 Address:_ ANDbVER MA 01810 City/State/Zip: Prone#: 5 �� ��d- 5-10'-5 Are you an employer?Check the appropriate box: ,. —, Type of project(required,. 1.91 I am a employer with_ ' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 5. F1 New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. j ' i. ❑Remodeling ship and have no employees These sub-contractors have 1 g, ❑Demolition working for me in any capaci-ty. employees and have workers' 1 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.j 5. ❑ We are a corporationn and its 10.[]Electrical rspai.-s or additions 1 3.❑ I am a homeowner doing all work officers have exercised their I 11.❑Plumbing repairs or additions Imyself o workers' com right of exemption per MGL y t p c. 1521(4), , 12.E]Roof repairs insurance required.] ' § and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box 4.1 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. tContractors that check this box?rust attached an additional sheet sh^wena t_ a + -c •!r he r.�ne of sub-or;_ac.or^�n a �and s?ste:.•teethe:or not.those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. F am an emplt?ver that is prom%ding vrorke,s'compensation insraance,l or my s niployees. Beloa,is'the policy and;ob site information. //�I Insurance Company Name: j1 O r6 V h k d\ ,Zn$ v C4 K re D vvi rl_}' Foli:-;#or Sclf-ins. Lia#: ?OCG 27-1-2-IT Expiration Date: of A, he,I� job Sitc Address: !0 OY1 rr",- `i 7- City/�tat:!Zip: �,►9� �I` Attach a copy of the workers'compensation policy declaration page(showing the polley 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. 11 do hereby cerci under the paiWs and enaltiew ofperjury that Fite information provided above is true and correct. Siaiiatare: 'Date9 /G71 Phone#: cl ),F- yob" 7& �6 Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# I Issuinng 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#: Location 319 No. �,' 0 Date . - TOWN OF NORTH ANDOVER "z Certificate of Occupancy $ Building/Frame Permit Fee $ 0 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# Building Inspector