HomeMy WebLinkAboutBuilding Permit #139 - 58 COUNTRY CLUB CIRCLE 8/21/2007 NORTh f
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TOWN OF NORTH ANDOVER
� . .>•'•' APPLICATION FOR PLA ATION
�SS�cHUSEt
Permit NO: /J e Received:
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION �v C- �� �•"' C4 '
Print
PROPERTY OWNER
//� rmt
MAP NO.: C� >>PARCEL: / ZONI G DISTRICT:
TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
New Building ❑One family
❑Addition ❑ Two or more family ❑Industrial
❑Alteration No. of units:
❑ Repair, replacement ❑Assessory Bldg Cj—�9"6, 61 ❑Commercial
❑Demolition
❑ Moving(relocation) ❑Other ❑ Others:
❑Foundation only
DESCRIPTION OF WORK TO BE PREFORMED
Identification Please Type or Print Cleaply)
OWNER: Name: iQ/�/� Phone:
Signature -
Address:
CONTRACTOR Name: ✓ > Phone:
Address: /�o ,/�i�'l,,'�/ cs� 'A , 0/1W3
Supervisor's Construction License: // Exp. Date: 730 6
Home Improvement License: 9 Exp. Date:
ARCHITECT/ENGINEER zi�G��/� Name: Phone: /p�79—X6e 2 —5 Z!'>' /
Address: a;Z;2 ?44
y eg.No. � 26
FEE SCHEDULE.BULDING PERMIT.$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PE Ij S. oTotal Project Cost :$ 109,C)6D x10.00=FEE:
Check No.: 07f� Receipt No.: 5-05-/(Oz::7
Page I o1`4
Location -5 �'D✓n &"�
No. 131 Date
01 NORTH TOWN OF NORTH ANDOVER
« e �1ti0 it
F 9
Certificate of Occupancy $
�,SJAOMUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ ,—
Check #
ii
20516
Building Inspector
TYPE OF SEWARGE DISPOSAL
Public Sewer / Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales 11
F1 Permanent Dumpster on Site ❑
Private(septic tank,etc.
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Signature of Contractor
Plans Submitted IV/ Plans Waived ❑ Certified Plot Plan St ped Plans LYJ
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
/ INTERDEPARTMENTAL SIGN OFF-U FORM
DATE REJECTED YTE APPROVED
PLANNING & DEVELOPMENT ❑
'gWater Shed Special Permit
❑ Site Plan Special Permit
❑ Other
COMMENTS / / J-S"j Vu Y► -,J-4 f,"4
DA JECTED PATE APPROVED
CONSERVATI
COMMENTSAS 4Pff2K JZ l�(q Vj T- Sn .P ( L
DATE REJECTED DATE APPROVED
HEALTH ❑ ❑
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water&Sewer connection signature&date
Temp Dumpster on site yes—no— Fire Department signature/date
Building Permit Approved and Issued by:
Page 2 of 4
Building Setback(
Front Yard Side Yard Rear Yard
Required Provided Required Provides Required Provided
Z/1-7
DIMENSION Qss
Number of Stories: Total square feet of floor area,based on Exterior dimensions. e7o
Total land area, sq.ft.: / Iz/
NOTES and DATA—(For department use)
o �
e` t 0A 1t7Y� J
Page 3 of 4
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Created 1MC.Jan.2006
f
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
Addition Or Decks
❑ Building Permit Application
❑ 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)
New Construction (Single and Two Family)
h 133l414kig4k-rApplication
€ ed Plot Plan
i Phet-a-e�f�:I- Vn- T-.S L. Licenses
;/W=kor- td t
;/Tvor e s o B—uilding Plans (One To Be Returned) to Include Sprinkler Plan And
lc Calculations (If Applicable)
0 ontract
Mass c ck Energy Compliance Report /VD l -{e,¢f
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of
Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and
proof of recording must be submitted with the building application
Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM05
Page 4 of 4
1
WOJCICKI McPARTLAND DEVELOPMENT, LLC
GENERAL CONTRACTING•CUSTOM HOMES
110 MAIN STREET
AMESBURY,MASSACHUSETTS 01913
TELEPHONE: (978)388-5829
FAX:(978)834-0733
April 18, 2007
Don Stanley
58 Country Club Circle
North Andover MA 01845
Re: 24 x 36 Two Car Garage
PERMITS: There is a $1,000.00 allowance included for permitting.
ENGINEERING: There is an $800.00 allowance for necessary engineering.
EXCAVATION:
• Excavate for new foundation.
• Backfill and compact interior of foundation.
• Trench from new garage to utility area of house.
• Backfill trench, loam and seed.
• Any blasting or rental of a hole ram would be additional.
LOT CLEARING: Not included in contract.
FOUNDATION:
• Pour 10" x 18" footing with two rows #5 rebar.
• Pour 8" concrete walls with two rows # rebar-4' walls.
CONCRETE FLOOR:
• Pour 6" wire mesh reinforced concrete floor.
FRAMING:
• Frame entire structure as per plan.
• All sub-flooring to be W Advantec.
• All wall sheathing to be '/ CDX fir plywood.
• All roof sheathing to be 5/8 CDX fir plywood.
• Install Tyvek wrap to entire structure.
• Install Vycor rubber membrane wherever necessary (windows, doors etc.).
• Install copper pan flashing on all doors.
• Copper flashing to be used wherever necessary (drip edge to be white
galvanized).
• All trim quoted as D-select pre-primed by WMD.
• All trim will be primed on all surfaces.
• All window casings to be shop manufactured by WMD and pre-finished.
PAGE 2
' ROOFING:
• All valleys, eves, dormer sidewall and first 3' of roof to have IKO Ice and
watershield installed.
• 15 Ib. felt to be installed on entire roof.
• All necessary venting to be installed.
• Install 30 year TAMCO Asphalt Architectural shingle to entire roof.
WINDOWS AND DOORS:
There is a $6,000.00 window and door allowance included.
ELECTRICAL:
• Run underground feed from existing house.
• Install 60 amp panel.
• Wire second floor to MA State Code.
• Install fixtures.
• Light fixture allowance $1,000.00.
PLUMBING:
:G
• Install ejector pump.
• Tie-in septic line in utility area.
• Tie-in water line in utility area.
• Plumb for sink in new garage.
• Plumb all necessary waste lines for future use.
• Install all necessarygas piping.
HVAC: Install propane fired American Standard furnace with all necessary supply
and returns. A.C. not included.
Option 1: Install gas fired modine heater in garage -$1,800.00.
INSULATION:
• Install R-30 in all roof areas.
• Install R-19 to all wall areas including garage walls.
• Install R-30 in floor.
SHEETROCK:
• Install 5/8 firecode to entire garage area.
• Install '/Z sheetrock to second floor.
• Finish all sheetrock with smooth finish.
INTERIOR FINISH:
• Trim all windows and doors with one piece 3 '/" custom casing.
• Install baseboard second floor.
• Build oak hardwood staircase to second floor.
FLOORING: Install the floor in first floor foyer area, $5.00 per square foot
allowance for materials.
PAGE 3
EXTERIOR PAINTING:
• Apply two (2) coats of 1St quality Ben-Moore latex to all pre-primed exterior
surfaces.
• All trim and siding to be pre-primed with an oil based primer.
• All necessary sealing to be done with a 25 year latex caulking.
INTERIOR PAINTING:
• All bare wood to be primed with Benjamin-Moore oil based primer.
• All plaster walls and ceiling areas to be primed with a latex sealer.
• All primed areas to be sanded smooth prior to finish painting.
• All nail holes to be filled and sanded and all necessary caulking to be completed
prior to finish painting.
• Apply two (2) coats of 1St quality Ben-Moore interior latex finish paint to all
prepped surfaces.
• Owner's choice of colors and sheens on all interior surfaces.
GARAGE DOORS AND OPENERS: There is an $8,000.00 allowance for purchase
and installation of two (2) garage doors.
GUTTERS: There is a $1,500.00 allowance included.
CLEANING: The entire structure and yard to be professionally cleaned at completion of
job.
LANDSCAPING: Re-spread existing loam and seed. No allowance included in
quote.
PAVING: Not included in quote.
TRASH REMOVAL: Dumpster to be kept on site throughout job, all construction
debris to be removed from premises.
EQUIPMENT RENTAL: A porta jon is to be kept on site throughout construction.
WE PROPOSE hereby to furnish materials and labor - complete in accordance with
above specifications, for the sum of$176,630.00. (See attached)
PAYMENTS TO BE MADE AS FOLLOWS:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above
specifications involving extra costs will be executed only upon written orders and prior
agreement on the amount of increased cost and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents or delays
beyond our control. Seller to carry fire, tornado & other necessary insurance. Our
workers are fully covered by worker's compensation.
NOTE: This proposal may be withdrawn if not accepted within thirty days.
Y PAGE 3
EXTERIOR PAINTING:
• Apply two (2) coats of 1St quality Ben-Moore latex to all pre-primed exterior
surfaces.
• All trim and siding to be pre-primed with an oil based primer.
• All necessary sealing to be done with a 25 year latex caulking.
INTERIOR PAINTING:
• All bare wood to be primed with Benjamin-Moore oil based primer.
• All plaster walls and ceiling areas to be primed with a latex sealer.
• All primed areas to be sanded smooth prior to finish painting.
• All nail holes to be filled and sanded and all necessary caulking to be completed
prior to finish painting.
• Apply two (2) coats of 1St quality Ben-Moore interior latex finish paint to all
prepped surfaces.
• Owner's choice of colors and sheens on all interior surfaces.
GARAGE DOORS AND OPENERS: There is an $8,000.00 allowance for purchase
and installation of two (2) garage doors.
GUTTERS: There is a $1,500.00 allowance included.
CLEANING: The entire structure and yard to be professionally cleaned at completion of
job.
LANDSCAPING: Re-spread existing loam and seed. No allowance included in
quote.
PAVING: Not included in quote.
TRASH REMOVAL: Dumpster to be kept on site throughout job, all construction
debris to be removed from premises.
EQUIPMENT RENTAL: A porta-jon is to be kept on site throughout construction.
WE PROPOSE hereby to furnish materials and labor - complete in accordance with
above specifications, for the sum of$109,000.00.
PAYMENTS TO BE MADE AS FOLLOWS:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from
above
specifications involving extra
costs will be executed only upon written orders and prior
agreement on the amount of increased cost and will become an extra charge over and
above the estimate. All agreements contingent upon strikes, accidents or delays
beyond our control. Seller to carry fire, tornado & other necessary insurance. Our
workers are fully covered by worker's compensation.
NOTE: This proposal may be withdrawn if not accepted within thirty days.
r
PAGE 4
1'
ACCEPTANCE OF PROPOSAL:
The above prices, specifications & conditions are satisfactory and are hereby accepted.
,PaKent will be 7de utlined above.
r b �
on Stanley Date
Mark Wojcicki Date
John Ja McPartland Date
Stanley,Don—TWO STORY GARAGE-CONTRACT—04-18-2007
December 5, 2007
Mr. Jay McPartland
Wojcicki &McPartland
110 Main Street AL
Amesbury,MA 01913 Fulcrum, Inc.
ARCHITECTS
Re: Stanley Garage, Country Club Estates,North Andover, MA
Dear Jay,
The BCI floor joist substitution installed at the Stanley garage project is an acceptable up-grade. The BCI
90 joist meets a live load deflection of L/480. The BCI 90 joists installed have a 67 lbs live load and a
total load of 113 lbs for a 24'-0" span.
Sincerely, '^
�c QLD AV,
F,
�O No. 9228
eR BOSTON"
en fa
Ronald N. Laffely,Architect ' `,` MAssor , ,:
r,,
22 Lafayette Road, Salisbury, MA 01952 Tel. (978) 462-5151 Fax (978) 462-5518 Email: fulcruminc@verizon.net
i r,rJ•a 'I1f,LC1s tp f
Residential Floor. Span Tables ..
About Floor Performance j
c great) due to the increase the joist dejot<h, limit joist deflections,giit9 and$Crew a
Homeowner's 6xpectetion�and opinion_..rya y
subjective nature of ratlrcg a new floor.Corn ,vitt!the th:ck+ar,tongue-artd-�rnvt�ve pports, install ilia Joists -od -C Vertically
ultimate end user to determine their expeC1Wian is colical. '�btatlon plumb with level-b6aring guppr�rts,and install a direct-teefached
is usually the Cause of Most complaints:Inst@iling latera!bridging muy Volling to the bottom(ranges of the joists.
help;however,syueoks may Occur If not instatled properly.SM0419 'I'i1G floor span tables listed beovi offer three very different
the joists Closer together'does little to affect the perception of the erforrriance options, based on perrarmance requirements of the
floor's performance,The+.lost common methods used to ined'easr� hCrrleovrner,
the performance and reduce vibration of wood floor systems is to
!
_FOUR STA_ GAOTION gMINIMUMSIFINIS cauroti
THREE STAR . F
LA I-oad deflection fhnited to U4507,.- Live Load detlaattOn limited to U950}:.if LIga Load deficotion iimitud to U3W
common Indust,!+and du;;!gn eommunity i jidoltfen to providing ti floor that is 100!9 alit cr I Flo,ys ihat meot Yro rrtinimum building eodu
siandard for rasid Vdai fl=)olsis,33%gtf#or r t4wki the three star floor,fiold cwperlenoe hoe I L1350 cilwria cru structurally 90und to Garry "
than L136D code minimum. however,tlpar b3Gn'lncorporried into.+J1a values 10 proVlda a thio at?ecitiad loads;however,thorn I :Youth
i padonrldneu play attl!ba on i sea In cartel ftr�r Wirt.a premium put' rmancu leval far t a higher risk er fiaor partOrrn9noe I„466. This
i mvpiicatlons,Uwacially with 91!7"and 1111+•" rr0,6 o:scrlml0atinjl homes:',11er. U41e should only be used oar aaolrcatigrs
! i 43CI" d6°9.P'}clots without
I s d1o91
.t�2+G."t-attached Ging,
m'h.e1r1e.f,owr perforance la rot=.Y COnrertl.
1£ 32- + 18" 192" 24^
o32.c"a.G. . e.g. C.C.2q" 32
Joist Joist OC.
th ries o o .
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5000s 1.8 17'-0" j 1@W" 1 r 14-1 2'5,1 ii'-+?` ii-5" 10-4 "•U'4" 971-g,1 1a 4 1�-7" 12,g 1
6000s 1.13 8'-2'' f 16'-A" ! 15'x" Id'F11' 1-6" 1"'-�" i 1D-C 1tV-rJ" i 14'-8° 20'-2°
20'
1 '-0" 11,01! 14' D" -•g" le-11" 17'710" 14-:"
55ons 1,8 1$'-8" ' 17�-'t`�l 3
5G4Db^1-.$-i+ 2D�9" `'19'-0" 131-111" 12 111 11'9". 23'-0" 20'--t" 1B'-6i"
iB'ri" 1x-4"
64003 1.6' 2V_r I 1° " 19-7 1?'-C i4'-tU" 1b 141-5" 7,t-5" 12l-1.123'-10° 21'-1W 204" 17'-'11" 14 X10"
1111x" t�5Dt1s1•${ 2Z'-2" 20'ti?1 fl 2
17-' 1 G,
q2'-7" 24'-6° 22 21'
1_5"
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flus 2.0 30'-1.. 4 7,_� z�
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• Span table is Lased on a restdo(Alsl floor lea:of Spa;va!U65 represent the mast restrictive of Gi rap�ryCat�Ona Wasdit-may bo possible to ecued thea
40 psf live load and 10 psf dead load(i2 psf dead 5imrle or mtlitlpt6 spars application,,. Ilrnit<ti0lis of this table by aRgl�zing i3 speclt'Jc
load for 90s 2.0 joists). Span va)uas art,ii)e maxlmvfn ailowabit clear appilaatlen wlLh the SC CALC+Sizing sotnvare,
Span values dSsOrna /,"rrdnlmum piywood1056 distance between SUIMPU:
rotted 8hesthi.'1g is glued arltl nailed to foists Tor Table values assume minimum bearing lengths
compesiie�rGtld+1 Uorsu sr�aGed at 32"ac.reiiulre v.'lihouf'xeb stif einem for joist deptim of 16"inch6E 1yh;rdpd vefuas t1U l�Ot$alts!�y.the rs'qulramaiits of
e'•laathing riled for such rpaci,g•1I;'plywcOdl and lees; 'hu North derchhe Stnlu.Suf/d1n0 Code Rofur to tho
o5t3) 'fNR0 S7AR table cW*r?spent'U9890•20tast!
Floor/Ceifing Assembly
ICC ESR 1336
FIRE ASSEMBLY COMPONENTS
1. Min.314"tangue•und-grOaVe plywood or-ice"APA Rated Sheathing
(Cxpouvre'I or exterior 0106)
2. BC It Joist:at 24"ac.or less,
3, Two layers'!;"type -ar two iayars 51D'Type X gypsum board
3
ONV TS
- � SOUND�1 ASSEMBLY COMPONENTS
When constructed with resilient Channels
*
Add carpet&ped to ire a5sembiy'l ST�64 i IIC�6 4r
- gad�11z"glass fiber Insulation to flre assembly; S�- Tc55 !_iii or
Contact your local 9atse rept0S5r f,3ffve for 5{}e^'%Ican aadl?ronal layer of rlinlmurr /a"shi sthing STC
astiernbiy information and eider f11r5-resisfiv0 Wti!rls. and 9'V;"gioss fiber Msulaiion to fire as: mbly: J L
TOF)/TOr,'ri F $$116fti2;LU6 S3141w ryti�11.�(� h "' ir i
TO !I= =.hl. I-lIi I;� ��;�, _it9�t�5�:l.atg -- =T _,'LiOZ; i
T)
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS - Z _ 0
Date
Building Location 610wners Name Dm oe Permit#
Amount
Type of Occupancy
New Renovation ri Replacement 1:1 Plans Submitted Yes No
FIXTURES
H z
a
W U z
O W 00 .a
H x x A x A A
W
Q
O
a � A A W H rain C7 A ad' � W
SMBM
B��vr
1ST FIDOR
?rII)Nwm
3M FLOCR
41H FLOOR
5M H-"
8111]FROCK -
7M HfM
91H MOM
(Print or type) Check one- Certificate
Installing Company Name � .
Address t,Acla C❑�Partner.
usmess a ephone Firm/Co.
Name of Licensed Plumber: I-) b
Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above
threeinsurance
signature Owner ❑ Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform d u PP Issued for this application will be in
compliance with all pertinent provisions of the sett and Chapter 142 of the General Laws.
By: um
Title
T P bing License
City/Town icense Numoer MasterJourneyman ❑
APPROVED(OFFICE USE ONLY
MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations /^ (1-411414
/
_ `7� l 4t lo'L 14f Zc3,m Permit
Amount$
Owner's Name
New Renovation Replacement D Plans Submitted
� a
w
w , c a a
F x y
c a a
Date f�2 .. .. .... w H u a r w
c z o W x
C > D off. W10
WOFTM
pf „to ,°�1.0
�� TOWN OF NORTH ANDOVER
O ...;. P
• PERMIT FOR GA.14NSTALLATION
•' h
�7SSACHUSEtS
t /
This certifies that . . . � . . .�. . . . . . . . . . . . . . . . . . . . . . • • •
has permission for gas installation . . •llfl? • • • • • • IrFirm/Co
e: Certificate Installing Company
in the buildings of . . ��`.'` `f t ? . . . . . . . . . . . . . . . . . . . . . . . . . . rp.
at . . . .�. • • ��•` K {�' %' G r` , North Andover, Mass. rtner.
Fee. t.�.�= Lic. No.&4? .
6AS INSPECT04 1 .
Check# �^j
6251 ne:
No13
D Bond 13
�a miy7�nsu�anc pe o icy Other type of indemnity
Owner's Insurance Waiver: I,am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
1 hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuse tate Gof the General Laws.
By: Signature of ensed Plumber Or Gas Fitter
Title 1:3 Plumber //�
City/Town Gas FitterIL cen a um er
Master
_ APPROVED(OFFICE USE ONLY) Journeyman
C The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): IoAr
�e� f�
Address: 61144�5 PL
City/State/Zip: 41_11flxv 1-106noe #: ��or-6 e/I
AV10amu an employer? Check the appropriate box: TyV�4epwrocjonstruction
ect(required):
1. a employer with 4. ❑ I am a general contractor and I 6.
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner-
listed on the attached sheet. E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. E] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.E] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#I 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 than hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#: �7 4Y C/
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#:
■ ■8/09/2007 10:35 GOULD INSURANCE 4 19788340733 NO.593 D01
■ I.
DATE(MM/DD/YVYY)
■■■q�CMD_ CERTIFICATE OF LIABILITY INSURANCE MCPAA-1 D0 09 07
■ uceR TH15 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Gould Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
7 Market Square ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Amesbury MA 01913-2494
Phone; 970-308-2354 rax:978 -388-5578 INSURERS AFFORDING COVERAGE _ NA1C#
INSURED INSURER A; Am9rican Rome Assurance Co. }I
INSURER e: Peerless Ins Co. _ _42064
McPartland Development Corp. INSURER C: Arbella Protection Insuranc I'
s y McPart�and --
1�5 9vans Place INSURER D: Safety insurance C2n2jaX 39454
Amesbury MA 01913 INSURER E:
I
COVERAGES
I
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TrIE POLICY PERIOD INDICATED.NOTWITHSTANDING n
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 DESCRIBEO HEREIN IS SUBJECT TO ALL TI-IC TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, EXP _
IHIJK NSRM 10TI 1
R
LIMITS
TYPE OF INSURANCE POLICY NUMBER DATE M DD e
T D (MM DD L
EACH OCCURRENCE 51,000,000
GENERAL LIABILITYUAMALih IV MEN
�( COMMERCIALGENERALLIABILITY CCP9697690 03/13/07 03/13/08 PREMISES&—a—feltce $50 000
CLAIMS MADE j]OCCUR MED EXP Any one pefaon) S 5�00 0
PERSONAL&AOV INJURY $ 1,000,000
GENERAL AGGREGATE s2,000 X000^
GEN'L AGGREGATE LIMIT APPLIES PER! PRODUCTS-COMP/OP AGG 8 2.,0_00 000
POLICY M JECOT PRLOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
C ANY AUTO 23538400000 02/27/07 02/27/08 (Eoeooi4enl) _r
ALL OWNED AUTOS BODILY INJURY $ 100,000
X SCHEDULED AUTOS (Per pereonl
X, HIRED AUTOS BODILY INJURY $300,000
x NON-OWNED AUTOS (Per euddanl)
PROPERTY DAMAGE 3100,000
IPer ucaldanq
GARAGE LIABILITYAUTO ONLY-EA ACCIDENT 5
ANY AUTO wOTHER THAN EA ACC $ �^
AUTO ONLY: AGG $
BXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 5
OCCUR L—I CLAIMS MADE AGGREGATE 3
S
DEDUCTIBLE 6
RETENTION S 5
WORKERS COMPENSATION AND DRY LIMITS E
A EMPLOYERS'LIABILITY WC1761931 01/08/07 01/08/08 El EACH ACCIDENT _ $500000
ANY PROPRIETONPAAYNEAIEXECUTNE �'—
OFFICERIMEMBER EXCLUDEO7 E.L._DISEASE•EA EMPL E $ 5_0_0000
Ifyes,4eocribaunder E.L.DISEASE•POLICY L IY 1500000
SPECIAL PROVISIONS below
OTNBR
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT f SPECIAL PROVISIONS
CERTIFICATE HOLDCR CANCELLATION
STANUY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO 4EAIL 15 DAYS wRITIEN
NOTICE TO THE CERTIFICATE HOLDER NA40ED TO THE LEFT,BUT FAILURE TO DO 30 SHALL
Donald Stanley IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
58 Country Club Cirolo
N. Andover MA 01845 REPRESeN TIVee.
AUTHORIZE AEIRE T V
ACORD 2612001/00) IS:I ACORD CORPORATION 1950
NORTH '9
0 0 t over No. /39 _
Z^ 4k 04
o 0
dower, Mass.,
.1.
COC NIC ME WICKo V
�oRATED P'PG "`�
v ` BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
Q�� BUILDING INSPECTOR
THIS CERTIFIES THAT......Z)D.A ........ ... ......................................................................................... Foundation
has permission to erect........................................ buildings on ........5 ...000.......{JM4_9. Rough
to be occupied as3.....e.A.0...... Chimney
provided that the person accepting th permit shall in every respect 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. �q/- 2&'4 zj�-',qz>p7-00/ PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
I 3 0 ir Final
PERMIT EXPIRES IN 6 MONTHS
UNLESS CONSTRU N STARTS ELECTRICAL INSPECTOR
Rough
Service
..... . ... . ... .........................................
BUILD ,SPECTOR
Final
Occupancy Permit Required to Occupy 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 Smoke Det.
Date......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...........
...... ................................ ....
..... ...
01 .
has permission to perform ............ ............................................
A --e/.
wiring in the building of...........pnv....5 .. .11 ......................
at......-ate~ . .........North Andover,Mass.
.......... ....... ...........
97
Fee.....5............ Lic.No...!.PAY.Y/ ........... ....
ELECTRI AL INSPECTOR
Check # FF3
`75 � 2
�-� Commonwealth of Massachusetts Official Use Only
SEXvim Department of Fire Services Permit No. Z Z,
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07) leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(M ),527 CMR 12.00
(PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 9 O P
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 151? Cov v-ri-y C L,,6 o j 1CAcF
Owner or Tenant .001,J Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box)
Purpose of Building JZce'%GPE}�v'Tt�/�
Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: re Qe
t
Completion of the followin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No,of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires l� Swimming pool Above ❑ In- ❑ o.o merge ig g
rnd. rnd. BatteryUnits
No.of Receptacle Outlets 8' No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. TotaTonal No.of Alerting Devices
No.of Waste Disposers eat Pump Number.. Tons KW No.of Self-Contained
Totals: _..._.......__... ......_.
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local E] Connection E] other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of WaterNo.of Devices or E ...valent
No.of No.of
Heaters KW Signs Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (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 F1BOND F] OTHER S ecify:) 1- t9 d i 4 < T'y
I certify,under the pains andpenalties ofperjury,that the information on this application is true and completes
FIRM NAME: .0/0!EX CF LIC.NO.:
Licensee: i" P i EX C e Signature4 '1/le, "�� LIC.NO.: � 6 9
(If applicable, enter exempt"in the license number line.) us.Tel.No.:Y78-3 p
Address: 1,::2,e S b "�'y /41,40.5-Y DC p/ Alt.Tel.No.:Y;>8' /S— .2 2 S
*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: $
i
{ V
75LI (A
r
f
gr
l .
The Commonwealth of Afassachusetis
Department of Industrial Accidents
-- - -- Office of Investigations._.
kv %600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information a Please Pri
nnt Legibly
Name (Business/Organization/Individual): /'f,F A C E JEL eGT/-1• C
Address: c� oi't9 09V
c
City/State/Zip: 49 "Yes d u,~y /'9'155 Phone#: `72-F -" 3 FY 30 01 o
of
r2.
re you an employer?Check the appropriate box:
Type of project(required):
❑ I am a employer with4. ❑ I am a general contraJi
employees(full and/orpart-time).* have hired thesub-co6 ❑New construction❑ I am a sole proprietor or partner- listed on the attached7. ❑Remodeling
ship and have no employees These sub-contractor8. ❑Demolition
working for me in any capacity, workers'comp.insur9 ❑Building addition
[No workers'comp.insufance 5. ❑ We are a corporation
required.] officer;have-exercise10.[y�trical repairs or additions3.❑ I am a homeowner doing all work right of exemption pe11.❑Plumbing repairs or additions
myself.[No workers'comp, c. 152,§1(4),and'we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] I3.0 Other
*Any applicant that chocks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they am doing all worts and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that isproviding workers'-compensation insurance for my employees Below is the policy mrd job site
information.
Insurance Company Name: F/-b e I L 19
Policy#or Self-ins. Lic.#: y4F,60, oe 06 Expiration Date:
Job Site Address: ,�g L°ov�vTi^�. L v C�i C f ef, /jay
City/State/Zip: eo
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 nsurarice Covera a verification.
ficatton.
I rlo hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: . %,
Date: T
Phone#: lC'��—' 38� �f 6 Q
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):
L.Board.of_Health.-2.Building Department-3:City/Town-Clerk-4.Electrical inspecior--5:Plumbing Inspector --
6.Other
Contact Person• Phone#•
1ACORD CERTIFICATE OF LIABILITY INSURANCE CSR LB DATE(MM/DD/YYYY)
PIERC-1 09/06/07
PR DUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Gould Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
7 Market Square ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Amesbury MA 01913-2494
Phone: 978-388-2354 Fax:978-388-5578 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Arbella Protection Insurance
INSURER B:
Pierce Electric, Inc. INSURER C:
2 Ora Ave INSURER D:
Amesbury MA 01913
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER P LICY EFF I E POLICY
L CY E PIRATION
DATE MM/DD/YY DATE MM/DDIYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ '5500,000
A X COMMERCIAL GENERAL LIABILITY 8500001486 01/01/07 01/01/08 PREMISESEaoccurence) $50,000
CLAIMS MADE FX]OCCUR MED EXP(Any one person) $5,000
PERSONAL BADV INJURY $ 5500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY PRO-
JECT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESWUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND
I
TORY LIMIN-
EMPLOYERS'LIABILITY TS ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE 90860508006 08/12/07 08/12/08 E.L.EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 5500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
NORTHAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN
Town of North Andover NOTICETO T E CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Electrical Inspector IMPOSE N OBLIGATIO R LIABILITY OF ANY UPON THE INSURER,ITS AGENTS OR
1600 Osgood Street
'In
N. Andover MA 01845 REP S TATIVES.
AUT R 'E TATIVII
ACORD 25(2001/08) OAC RD CORPORATION 1988