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Building Permit #666-11 - 57 OLYMPIC LANE 3/31/2011
BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Y/ 4� _( ( Date Received Date Issued: '07 ' 5 / IMPORTANT: Applicant must complete all items on this page LOCATION % 0/ yM l oc L `)FA► e -- f� Print PROPERTY OWNER /L Gil t r � E;i e UW&,, Ree. V P - MAP 210 A Z PARCEL v'tt�eo 16`•ryO\ C? � ^� ey Print ZONING DISTRICT: Historic District yesrn Machine Shop Village ves TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building 40nefamily::' Addition wo or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other S tic Well Floodplain Wetlands Watershed District cllw-aterisewe—r') D SCRIPTION OF WORK TO BE PREFORMED: New ;/°a rce illi� %�J e/'ecTrIc-1 14 �gNiry, pD Poe%e7- N,&r To eNir��C X%TTi,uq �Qri�4 Identificap n Please Type or Print Clearly OWNER: Name: Phone(27Ja -5-r!0W Address: �fy%yt�%c CONTRACTOR Name: '0 oW e res' Address: L?NJNq Z)- rwvi/% )a? 3 5 7 i �3P1 Supervisor's Construction License: 78'0145) Exp. Date: /,A 0 / t Home Improvement ARCHITECT/ENGINEER /*�)//l 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: $ 1��� FEE: $ ! �� Check No.: Receipt No.: '�M NOTE: Persons contracting with unregistered contractors do not have access to the guaran d Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Conservation Decision: Comments Zoning Decision/receipt submitted yes Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: t_ocatea 384 Usgooa 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 - 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) ❑ 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 2008 Location 4,,o, - /Z No. A--4, Q�, ,"/ I Dat. TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Mu Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / � & 3 2 4 U 1 2 \,P� Building Inspector 4, 1 Date -52, (I... Mli X- /. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .................. has permission to perform ... 2.q.4'e.a. . .............. plumbing in the buildings of ...... .................... at lz��IliA— North Andover, Mass. Fee.3 T� Lic. No. 1.().7c) PLUMBING INSPECTOR Check ff 1NI IN MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: AZo,2Y4 ry pl MA. Date: S 3 2v% Permit# Building Location: S7 Oe. //l�42c—c Z,,,#kjoF Owners Name: elf Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential Q - I New: U Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted Yes ❑ No ❑ FIXTURES w z S HDEDICATED Y O LLJ ZLn Ln t/f a Z F- Y Q Q W Z I••' Z I"" = H Uj c Q Z ¢ N W _W Ln Q N = {ALn cc z -j Q W c Q Z CC K z Z C I=., to Z - d x Z N = _J a I.W., 3 s Q Y = 3 O = 0 0 W N O ~ U > > O Q a j Q 0: Z Z of I.- F W C,3 D W � I Q } W F- a m m o o LL °x Y g g� N N IQ- D 3 3 3 o a 0 3 SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR Installing Company Name: Check One Only Certificate # _���i�u.v rs• T`/T El Corporation Address: /vs"��a/FS �� City/Town: fi /.I /state: • 0 386r El Partnership Business Tel: 6 03 -382 - Wle- Fax: 603 - 36'2 -5Zif ❑ Firm/Company Name of Licensed Plumber:TA#S /=442/W -x INSURANCE COVERAGE: I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes "o ❑ If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy W Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑ Plumber 41 U —:of Licensed Plumber Citylrown aster APPROVED OFFICE USE ONLY) ❑Journeyman License Number: 107251 www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf f,caibly Name (Business/Organization/Individual): a" �� � Z Address: ;? Ali 4C fo c r tz J City/State/Zip: Pj4 dsfac cj kh o 3er j Phone #: 6 ()3 3 g 2- Zi 6�V 2 Are you all employer? Check the appropriate box: The Commonwealth of Massachusetts c ,.-� 1 1 Department oflndustrial Accidents . 1 , 1. i Office of Investigations 6..'U 600 Washington Street Vtlei ! Boston, MA 02111 www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf f,caibly Name (Business/Organization/Individual): a" �� � Z Address: ;? Ali 4C fo c r tz J City/State/Zip: Pj4 dsfac cj kh o 3er j Phone #: 6 ()3 3 g 2- Zi 6�V 2 Are you all employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I air 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. [1 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.] f 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 11.❑ Plumbing repairs or, additions 12.❑ Roof repairs _ 13. ❑ Other *Any gpplicant 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 anew 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: 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 fonn 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 maybe forwarded to the Office of Investigations of the DIA for insurance .coverage verification. I do hereby certify under tft pains and penalties ofpetjury that the information provided above is true and correct S/3/2n Phone #• 'G U 3 3 V Z y( !KZ -- 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the ' dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or.on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation'affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 cavy workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation of insurance coverage. AIso be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any. questions regarding the law or ifyou are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pennWlicense number which will be used as a reference number. In addition, an applicant that must submit multiple,,pennit/license applications in.any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts DQpartmeut of Industrial Accidents Office of Investigations 600 Washington Street. Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia c. l H Vr, VlA'bAt;flUZ)C t 1 5 'UMMUNUvCw • . • 11 ER PLUMBER 1 -1 LICENSED AS A MAST, ISSUES THE ABOVE LICENSE TO: JAMES K FLATHERS N. �m 7 NICHOLAS RD N PLAISTOW NH 03865-2222 j 10724 05/01/12 783329 r `• IV CA \1 V O z. I R-71 x A . v w � U) m U A Oa cis wo C2 U —co w O w ao' —co w oAG W �2 U) ICD o, o a_ W4 ._ - U) v o cn Ir .r C ,0- c �;c o �+ Cl p y vO V CL C ea ea ; 0 O +' Cc O f �a CF 4 mM �Z �o n N c �mCL C N _R m m Cl �: N N m 3 cm m a C C m : I-- N Em � m o C.C. i N m +_+r=.+ O 'O c as N OILC10L C1 mA:' O ' Z c � H o. o = m m_... 3 O :a rO COD N m ~ EH COLL. yr C •+ CA O.L O C ... oc 'E v w N C.3 4D V� a m m HBO O d � N N O V! C O O! /n Ir Of C m 0 cm C �C N m t O Z 0 CD z O U C/) M W LLI U) LUN W W oc W N L 0 Z co O D y C ICD o, o CD ._ a w m m CD CL w �+ CD O a� 0 CDL C3 cc 0 CL cma c c-10" C ccc v .� JCIO .0 t; co V y R C • C _cc Q. h 0 LLI U) LUN W W oc W N 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 Inf rmation r� 5-7 0/ reel Address (do is L -Ne- use a Post Office Box address) N rrA ljmWo wr wsr, olg�. Cityffown Stale Zip Code Daytime Phone Evening Phone Address (It different from The Contractor agrees to do the following work for the 11 Contractor information __9RAD Powers ca, Js r—rUC 7-1`t5)1V _nmpany Name _�_ R/q/---> /�oWers "ontractor/ Salesperson/ Owner Maine / _A a (N, �J N4 crN�' tq,&1 % N q lusiness A—ddreessrmust include a street address) 'D ---3N V i/ 1e__ N q o 3 :ilyfl own State Zip Code X03 0? -3 7 61K/p oa f 7 It - Business Phone qederal Employer ID or S.S. Number law requires that most home hit- name proveenl Conmetor Reg. Nber Expbminn date p pmvmtent comramnrs haves I `�fe "j m/a -'� 7um110 f f 61,2 e l � D9,9 lid n,gistratian owotoa /` 7� t22i1'tocQe / /--L)// a1ra11 oGv ri,�'¢�L ��2 • /Ue ov IA'/d o2, Ce�%iNJ7 7-vb 7b>'/e %V59N) 1 7y V -?,v ry TSP � SiNk f W/¢// j�4TcLies;/Vf w iiUs�/4T/�NC��jer 2eNoVYTioN�C'u✓%�re�o4�Q Tll�- dN /vol Yro�N� y-c�b S�Ii^ot�Nc�J�/@(,J PeXh-7L'rr Ps.v VeN(Jac,r J eleGrricgl ClzaNrjes p�lJrnb:N� Q�bt7ri�9J L`9bb/L PerMi rr� J�RThr,.n1 '1gy"Ur- ry : TZY s j s ex cep T dose r_'Jev�o dispas4 ( �' D �tl`/ C/t®� V,0 Poc.,txr- Dave ro 8�r//II%eenl eft'/�; y Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule will fist y'S and will be secured by the contractor as the homeowner's agent, be adhered to unless circumstnnces beyond the contractor's control arise (Owners who secure their own permits will lie ` gAsQmc�t p excluded from the Guaranty Fund provisions of —a5/Date when contractor will begin contracted work. v/ �rQ MGL chapter 142A.) 9—// _. 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: _(*) Payments will be made according to the following schedule: $ 06 o . upon signing contract (not to exceed 1/3 of the total contract price/ or the cost of special order items, whichever is greater) S 3000. by 5f -al l or upon completion of / � %necAwic-t15 /�I�3 x7 S ¢dD�. by 5 / / / / / or upon completion of /��� �/S'N�`7X � TOP S upon com letion of the contract. Law forbids demanding full payment until contract is completed to both party's satisfaction Tile following material/equipment must be special S a00 el to be paid for _rl Y"O— 4 Vs-N/,?'Y 4. ordered before the contracted work- begins in order S o0 ___ to be paid for QJv M 5 i w<; r /` rriYe-t 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 Warranty As an express warranty belne provided by the contractor? -ZQ Yes (all terms of the warranty must he attached to the contract) Subcontractors - T6eicontractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aereement 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 fidly understand it. Ask questions if something is unclear. • M eke sure the contractor hos a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be registered with die Director of [ionic ltitprovulienl 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 617-727-7200 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 Horne Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor 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 third business day following.the signing of this agreement See the attached notice of cancellation form for an exploitation of this right, illi lU /lT atilt Al rs .- i-. vv ,.v ■ `1"1'R 11 rile L"IN I VLA -k..1 111 1.liLatLt AKL ANY 13LANK SPACES!!! /wo idetti I copies ofthe ntract must be completed and signed. one copy should go to the homeowna. The other copy should b ept the contractor Signature Contractor's Sigr ire Date ' Date 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 herebymutually 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 Secre ry of We Executive Office of Consumer Affairs and Business Regulation and the consumer II be required to sub' L to sucIarbitration as provided In Massachusetts General Laws, chapter 142A. omeowner's Signature Contractor's tgnat'ne oll NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative disput resolution initiated by the contractor. The homeowner may initiate 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 right's if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Horne Improvement Contractor Law. The contractor is responsible for completing the work as described, in a timely and workmanlike maumer. 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 fatness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be added to the terns 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 duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to We 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/irerself 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 We contracted worlc. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional inforination about the Home Improvement Contractor Law or other consumer rights, orif 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 (617) 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 I"' PrOvemellf 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 Attomey General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508) 75.5-2548 (4 13) 734-3114 Date ... :�� . ... C;�P ...... "9.... . ....... . ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ! ................ ........................................... . .. .. .... .... has permission to perform ........ n., ....... 1 ............................................ ................. wiring in the building of .... : .......................................................................... at ..... North Andover, Mass. ................ Fee4;�� .. . ........ Li'C. No:,:77-.'-.MA,-I/i ............. Check # 8719 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only 71PI07] �7% 9 d Fee Checked (leave blank APPLICATION FORPERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME 527 CR 12.00 (PLEASE PRINTINIATK OR TYPE ALL INFORMATION) Date: 4�1, City or Town of: NORTH ANDOVER To theInspe foes: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) S7 (� 7/M P ` C LQn 2 Owner or Tenant Telephone No. Owner's Address sayy)� Is this permit in conjunction with a building permit? Yes1C No ❑ ❑ (Check Appropriate Box) Purpose of Building S;y-,5- Lam" \ `) Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the followinj No. of Recessed Luminaires 3 No. of Ceil: Susp. (Paddle) Fans No. of Luminaire Outlets No. of Hot Tubs No. of Luminaires Swimming Pool Above ❑ In_ ❑ d. grnd. No. of Receptacle Outlets 10 No. of Oil Burners No. of Switches -9 No. of Gas Burners No. of Ranges No. of Air Cond. Total No. of Waste Disposers Heat Pump Number Tons I Totals: _....._............_ No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Appliances KW No. of Water No. of Heaters KW No. of SAMS Ballasts No. Hydromassage Bathtubs INo. of Motors Total HP OTHER: V1 table may be waived by the In.anorinr —1W;— . of - - -1.... Nootal T Transformers KVA Generators KVA o. o mergency ig g Batte Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices rting Devices -Contained VDetieetion/Alertin Devices unicipal ❑Other onnection Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent Telecommunications Wiring: No. of Devices or E uivalent OO Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q(�') (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �q BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: '0\0 SAO Licensee: "s p;CG�� Signature (If applicable, enter "exempt" in the license number line.) ��~ LIC. NO.: Address: ) �{ 6C / � � Bus. Tel. No.: ) — i Alt. Tel. No. yti- *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: kj�' f M t'; www nzms.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaylicant Information (� Please Print Le�bly Name (Business/Organizationnndividual): P J crac o, eve Address: OA SW The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 City/State/Zip:_ SGV'�(.) v� a _QJ 900 Phone #: )e Are you an employer? Checkthe appropriate box: 1.P 't K Type of project (required): a employer with VV employees (full and/or part-time).* 4. Q 1 am a general contractor and I have hired the sub -contractors 6• ❑ New construction 2. ❑ I am asole proprietor or partner- listed on the attached sheet. = 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. Q Demolition working for mein any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑Building addition required.) aired 3. ❑ I am a homeowner doing officers have exercised their 10.❑ Electrical repairs or additions all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No -workers' comp. c. 1.52, § 1(4), and we have no 12T1 Roof repairsinsurance required.] t employees. [No workers' 13.❑.Other comp, insurance required_] - — -• ��x tl, MUSE aiso nu our ttre 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 anew adavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their Workers c np. policy isatin such. I ant an employer that is providing:workers I compensation insurance for information my employees. Below is the policy and job site . Insurance Company Name:�Q�G112�`� Policy # or Self -ins. Lie. #:_(D-1 b 9 9 W Expiration Date: Job Site Address: 1 F I'L 2 City/State/Zip.L 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 certify under the pains and penalties of perjury that the information provided above is true and correct Phone #: `i� f �� f j 3 Fficial 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Pi um 6. Other bing Inspector Contact Person: Phone #• ' aT Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance 'coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not'the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number_ listed below. Self-insured companies should enter tI?eir self-insurance license number on the appropriate dine. 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitllicense applications in any given year, need only submit one affidavit indicating -current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. h The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call �y The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, IIIA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7741 www.mass.gov/dia OP ID: ST ,4�� zc� CERTIFICATE OF LIABILITY INSURANCE DATE(/30/1YYYY) 03/30/11 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 603-382-9211 THE JOSEPH S. HILLS AGENCY INC 129 MAIN STREET, PO BOX 300 603-382-3387 PLAISTOW, NH 03865-0300 CONTACT NAME: A/� No Ext : AC No): E-MAIL ADDRESS: GENERAL LIABILITY PRODUCER POWDBA1 CUSTOMER ID #: INSURERS) AFFORDING COVERAGE NAIC # INSURED Bradley Powers, Jr. dba INSURERA:NGM Insurance Company 14788 Brad Powers Construction. 22 Wyman's Landing Danville, NH 03819 INSURER 8: INSURERC: INSURER D: INSURER E: 02/04/12 INSURER F : MED EXP (Any one person) $ 10,000 COVERAGES CERTIFICATE NUMBER: 11-001 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 REDUCED BY PAID CLAIMS. INSR LTR 7ypE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F_x1 OCCUR MPB9290S 02/04/11 02/04/12 DAGE T R NT D PREMMAISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY X PRO LOC _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO —' BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) $ NON -OWNED AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ _ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS' LIABILITY Y/N TORY LIMIT$ E E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? r7NIA E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Carpentry residential Job: 57 Olympic Lane L;tK I II-IUA I t h Town of North Andover Attn: Building Inspector 1600 Osgood Street Bldg #20 Suite 2-36 N. Andover, MA 01845 NOANDV1 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 O� ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Ma,"achusetts - Qepartment of Public SOW, Board of Building Regulations and Stan Go tstrulrfm Supervisor License License: CS 48810 - - Re tided 9. 00, t BRADLEY POW-ERu A 22 WYMA .T- A ANC #40 DANViLLE 103810 �,ri'..-�.- _-� •-� Expirat�ri �,Sf3J�(3�1��,� h 1 t'<aaisvycanne Tr## 1515 Q ;torigum°�eraarlivai es - HOME IMPROVEMENT CONTRACTOR Registration: ;,122776 Type: Expiration: DBA BOWERS GfT#CT1N BRADLEY POWEWJ:%1' 22 WYMANS LANDfNG A,- , .'' DANViLLE, NH 03819,:. v Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvestigations 600 Washington Street Boston, MA 02III www -mass gorldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lea><bIy Name (Business/Organiza6on/Individual): �{�� � pow "' l^ S Address: o2 a W,_ y/M9`v J City/State/Zip: Z)4>/JV;//e /*() /7' 0300/9 Phone &,`3 �2-�5-%9, Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2.'?'`am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet I 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. 021[emodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other -, vut u:c 5eclon neiaw snowin._� T.^eFS work--tcomp--sat ion compon Policy inform on. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showingthe name of the sub contractors and their workers' comp. poIicy information. lam an employer that is providing workers' compensation insurance for my employees, Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Address: Expiration Date: 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 Z;7==// erjury that the information provided above is true and correct Si ature: / v7 ST Phone #: &,o3 3 — 7 ��' Date.: [[�I. fficial use only. Do not write in this area, to be completed by city or town. official. ity or Town: Permit/License # suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector Otherntact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 15.2, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, net the Deparbrent of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass.gov/dia