HomeMy WebLinkAboutBuilding Permit #367-16 - 8 ALCOTT WAY 8/21/2015 ,n 92 9//1s
BUILDING PERMIT NORTH
OF,�i�eo
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION p
^ pp
Permit No#: (.�\I(' Date Received
gSSACHU`'�(
Date Issued:
IM RTANT: Applicant must complete all items on this page
LOCATION411-;uMlp W
YJ Print
PROPERTY OWNER
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
epair, replacement ❑Assessory Bldg ❑ Others:
Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Iden ' 'on a - lease Type or Print Clearly
OWNER: Name: f)p- a Phone:
Address: 61 co ter.
Contractor Name: 5 w e Phone:
Email: Cp ' NC
Address:
Supervisor's Construction License: C S" 6.r Exp. Date: *?J3 f -)8 16
4
Home Improvement License d1 Exp. Date: l�
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: $ FEE: $ �
Check No.: Receipt No.: 1
NOTE: Persons contracting with unregistered contractors do not have access to h` g a fund
dna jr of AaPnt/Owner __
Location (l ►��"
No. '�! N Date 1
TOWN OF NORTH ANDOVER
ti ft Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ "
Other Permit Fee $
TOTAL $
Check#
3
Building Inspector
2 le 3 3
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 Duimpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT Reviewed On Signature_
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
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COMMENTS
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
e e �
Planning Board Decision: Comments
U
Conservation Decision: Comments
Water& Sewer Connection/Signature Date Driveway Permit
DPW Town Engineer:-Signature:
Locate_d 384 Osgood Street
;YFIRE aR�TMENT TempDumpsterhonisite 1yes
;iLocated at��1e24iMaintStreeti
{Fire(®epaTtireldate;
- i
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location mast
or service drop requires approval of
Electrical Inspector Yes No
DANCER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— (For department use)
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❑ 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
4 Building Permit Application
4 Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
4� Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
IN OTE: 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
OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
t
New Construction (Single and Two Family)
4 Building Permit Application
4 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
2012 IECC Energy code
4. Engineering Affidavits for Engineered products
OTE: 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
Enter construction cost for fee cal- North Andover Fee Cakulatlon
Construction Cost
$ 42,500.00 m
$ - $ 510.00
Plumbing Fee $ 63.75
Gas Fee 100 comm. $ 100.00
Electrical Fee $ 63.75
Total fees collected $ 737.50
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8 Alcott Way
367-2016 on 8/21/2015
Kitchen Remodel
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NORTH
Town ndover
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RIP 1 .�'
h ver, Mass,
coc NIc Ml WIcK y1'
ORATED rp�`�.(`�
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT , S O;.64 00„ BUILDING INSPECTOR
.................. Foundation
has permission to erect.......... ............... buildings on .......�........I!�l.l�. .....�....
Rough
to be occupied as .......
......................r............................................................................................ 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 CONST TIAt
RTS Rough
Service
.. .... ..... ..... .. .......................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
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9"- 24'
-33"- �-3'0"------.' 33"----
171 z„--
All
–All dimensions-size designations 20 2011This is an original design and must Designed: 4/25/2014
i given are subject to verification on oioE not be released or copied unless Printed: 4/25/2014
i job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
8 Abbott Way Kitchen 4-25-14 DIA.kit All Drawine#: 11 No Scale.
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JSA Companies Home Improvement Contract
This form satisfies all basic requirements for Massachusetts'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 617-9738787 or 1-
888-283-3757.
Home Owner Information JSA Companies Information
Name: JSA Companies
Joe Sabella
Street Address: Owner:Jeff Agnew
8 Alcott Way
City/Town State Zip Code 55 Chase St.
North Andover MA 01845
Day Time Phone Evening Phone Methuen, MA 01844
(603)498-2606
Mailing address if different from above (978)375-8041
Additional Licensing Information(may differ depending
upon scope of work)
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JSA Companies agrees to do the following work for the homeowner:(additional pages may be attached
as necessary)
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Required Permits—The following building Proposed Stated and Completion Schedule—
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permits are required and will be secured by the The following schedule will be adhered to unless
contractor as the homeowner's agent: circumstances beyond the control of JSA
(Owners who secure their own permits will be Companies emerge.
excluded from the Guaranty Fund provisions of
MGL chapter 142A) Date when JSA Companies will begin
project
Date when contracted work will be
substantially completed
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Total Contract Price and Payment Schedule—
JSA Companies agrees to perform the work,furnish the material and labor specified above for the total
sum of: $42,500.00 (*)
Payments will be made according to the following schedule:
$ Upon signing contract(not to exceed 1/3 of the total contract price or the total cost of
special order items,whichever is greater)
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$ by or upon completion of
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$ by or upon completion of
$ by completion of the contract. (Law forbids demanding full payment until contract is
completed to both party's satisfaction)
By leaving the scheduled payment terms blank above,the customer has agreed to pay the lump sum
payment upon substantial completion.
The following material/equipment must be special ordered before the contracted work begins in
order to meet the completion schedule.(**)
$ to be paid for
$ to be paid for
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—Is an express warranty being provided by JSA Companies? X NO YES
(terms of the warranty are attached to the contract)
Subcontractors—JSA Companies agrees to be solely responsible for completion of the work described
regardless of the actions of any third party/subcontractor utilized by JSA Companies.JSA Companies
further agrees to be solely responsible for all payments to all subcontractors for materials and labor
under this agreement
Contract Acceptance—Upon signing,this documents becomes a binding contract under law. Unless
otherwise noted within this document,the contract shall not imply that any lien or other security
interest has been placed on the residence.Review the following cautions and notices carefully before
signing this contract.
• Don't be pressured into signing the contract.Take time to read and fully understand it.Ask
questions if something is unclear.
• JSA Companies can provide verification of proper insurance and licensing at the homeowner's
request.
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DO NOT SIGN THIS CONTRACT If THERE ARE ANY QUESTIONS THAT REMAIN UNANSWERED
Two identical copies of the contract must be completed and signed.One copy should go to the homeowner-The other copy will be kept by 15A
Companies
Homeowner's Signature jCoPu ?brilzed --
f
Date Dat
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Notice of Cancellation
You may cancel this transaction,without penalty or obligation,within three business days from the
above date.
If you cancel,any property traded in,any payments made by you under the contract or sale,and any
negotiable instruments executed by you will be returned within ten business days following receipt by
the seller of your cancellation notice,and any security interest arising out of the transaction will be
cancelled.
If you cancel,you must make available to the seller at your resident,in substantially as good condition
as when received,any goods delivered to you under this contract or sale;or you may,if you wish,
comply with the instructions of the seller regarding the return shipment of the goods at the seller's
expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days
of the cancellation,you may retain or dispose of the goods without any further obligation:"tf:-youfiail to
make the goods available to the seller,or if you agree to return the goods to the seller and fail to do so,
then you remain liable for performance of all obligations under the contract.
To cancel this transaction,mail or deliver a signed and dated copy of this cancellation notice or any
other written notice,or send a telegram to 1SA Companies at 55 Chase St Methuen, MA 01844 no later
than midnight of Sept. 12,2015 (date).
I Hereby Cancel This Transaction
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Date: Buyer's Signature:
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_M Commonwearth ofMas�sach�c�eis
. _ Department of Induse` alAccz�et�t�
X Congress Sheet,Solite 100
Boston,MA.02114-2017
www mass go vMax
Workers'Compensation Xnsuranice Affidavit:Builders/Cont ractorsLElectricians/Plunabers.
TO BE MED WITH THE PERAffI TING AUTI11012ITy-
A Ecant Information Please Print Ledb
Nannie(Bus al) r
AAdxess: �
City/state/Zip: 11ye 1 U4,w.6L;Whona#: ( 7 "32�7—,YO-------------
71
Areym on employer?Checkthe appropriate box: Type of project(required):
1.❑I am a employer with ! employees(full and/or part-time).* 7. ❑New construction
2. I am a sole proprietor or partnership and have no employees working forme in 8., 'Remo dalitig
any capacity.[No workers'comp.insurance required.] 9. Demolition}(�J
3..Q I am a homeowner doing all workmyself[No workers'comp.insurance required.]t
10[]Building addition I.
4.[]S am a homeowner andwill behiring contractors to conduct all work on my property. Iwill
ensure that allcontractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof rep airs
These sub-contractors have employees and have workers'comp.insurance.*
6.❑We are a corporation and its officers have exercised their right o£'exemption perMGL C.
14.F1 Other
152,§1(4),and we have no employees.[No workerscomp.insurance required.]
xAny applicant that checks box 41 must also fill out the section below showingtheirworkers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must siibmit anew affidavit indicating such.
?Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workeis'comp.policy number.'
I am an employer tfiiat ispfo'viding workers'compensation insurance for my employees.' Below is the policy andlob site
information. �
Tnsurance Company Name: —
Policy#or S elf-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation-policy declaration.page(shoving the policy number and expiration(late).
Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by 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 ofup to$250.00 a
day against the violator.A,copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ee u tl pains rad Coes ofperjuiy Haat the informationprovided4vap true and correct.
Si na Date
Phone#:
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): i
1.Board of Health 2.Building Department 3.CityJTown 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,asso ciation,corporation or other legal entity,of 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 numher(s)along with their cert icate(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 au LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department.of Industrial
Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. Via 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 ifyoifare 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of TndustrialAccidents
1 Congress Street,Suite 1.00
Boston,MA.021.14-201.7
Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE
Fax 4 617-727-7749
Revised 02-23-15 wwwmass.gov/dia
ACORV CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
`..../ 08/24/2015
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 KEITH 13EAUSOLEIL
NAME:
FORTIFIED INSURANCE AGENCYacco"no E ,603-644-3700 INC,No 603-644-0001
911 CANDIA ROAD E-MAIL
ADDRESS: INFO FORTIFIEDINS.COM
MANCHESTER NH 03109 INSURERS AFFORDING COVERAGE NAIC#
INSURER A: MERCHANTS MUTUAL INSURANCE CO
INSURED INSURER 8: _
JEFF AGNEW DBA JSA COMPANIES INSURER C:
11 ESTHERDR INSURER D:
BEDFORD,NH 03110 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, j
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POY EXP
LTR TYPE OF INSURANCE p POLICY NUMBER MMIDDIYYYY AMLMICDNYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY BOP1084614 04/09/2015 D410912016 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE F OCCUR
DAMAGE T RENTED 500 000
PREMI ES Ea occurrence $ ,
MED EXP(Any one person) $ 10,000
PERSONAL 8 ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY�JECTPRO- LOC PRODUCTS-COMPIOPAGG $ 2,000,000
OTHER: $ I
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea acadent
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIREDAUTOS AUTOS Per accident $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? N I A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required)
RESIDENTIAL PLUMBING AND CARPENTRY REMODELING
CERTIFICATE HOLDER CANCELLATION
TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
INSPECTIONAL SERVICES ACCORDANCE WITH THE POLICY PROVISIONS.
1600 OSGOOD STREET
BUILDING 20,SUITE 2035 AUTHORIZED REPRESENTATIVE
NORTH ANDOVER,MA 01845
GC 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Superr-isor
License:CS.065690
JEFFREY S AGfq-%V
55 CHASE ST ~^r n
MEMEN MA 81844. I
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�= Expiration
Commissioner 07/31/2016
i
�e �aananza�zrue�c�lf o��/�irsac�uaet�J
_Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
.egistration: 172928 Type:
Expiration: .-8!1412016• Individual
JEFF S.AGNEW
JEFF AGNEW
11 ESTHER DR. _
BEDFORD,NH 03110
Undersecretary i
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PO 60X55098
Boston,MA 02205-5098
617-951-0600
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER,MA 01845
RE: Insured: JOSEPH SABELLA
Property Address: 8 ALCOTT WAY,NORTH ANDOVER, MA
Policy Number: HMA 0223321
Claim Number: BOS00052860
Date of Loss: 2/5/2015
Company: Safety Insurance Company
Claim has been made involving loss,damage or destruction of the above-captioned property,
which may either exceed$1,000.00 or,cause Mass. Gen. Laws, Chapter 143, Section 6 to be
applicable. If any notice under Mass.Geri. Laws, Chapter 139, Section 3B is appropriate,please
direct it to the attention of the writer and include a reference to the captioned insured,location,
policy number, date of loss and claim number.
Eric Keenan Claim Examiner 3/3/2015
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3548
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Fax: (617) 531-6676
Email: EricKeenan@Safetylnsurance.com
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Date......
� pORTN
" "°0 TOWN OF NORTH ANDOVER
o
p PERMIT FOR WIRING
ACMU5��
This certifies that ................"...........-'�!/ � /-- ................................
haspermission to perform ...........� .......................
wiring in the building of................... f 4.,5......................................
at................... ..../ G.. ? '..... Y.......... ,North Andover,Mass.
Fee... s..'.... Lic.No.T b .y 3...... .
EcecrIuc,u.IrSrBcroR
� Check # �Q� '
11656
Commonwealth of Massachusetts Official Use Only
Permit No.
1 f,� Department of Fire Services
'r' Occupancy and Fee Checked
t BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank
F
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the M�saebusetts Electrical Code WEC),5Z7 C 12.00
(PLEASE PMTEV INK OR TYPE ALL INFORMATION Date: Ql ff'1 0
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives otice of his or her intention to perform the electrical work described below.
Location(Street&Number) `/j J�Z cd 7
Owner or Tenant e l_a { Telephone No.
Owner's Address /9 L r,e-7 ,tea y
Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Boa)
Purpose of Building Utility Authorization No.
Existing Service 1W Amps t W / 2 w dVolts Overhead
❑ Undgrd;H- No.of Meters _L
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: Z 1ST�147�w o- -7—
Completion
Com letion o the ollowin table may be waived byv 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 SwimmingPool Above In- o.o mergency ig g
rnd. ❑ rnd. ❑ Batte Units
No.of Receptacle Outlets No.of Oil Burners To.
E ALARMS No.of Zones
No.of Switches No.of Gas Burners of Detection and
Initiatin Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump Number.Tons KW No.of Self-Contained
Totals: ""'"' Detection/Alertin Devices
No.of Dishwashers Space/Area HeatingKW Municipal
Local❑ Connection ❑ Other
No.of Dryers Heating Appliances , Security Systems:
o.of Water No.of
Heaters KW Si No.of Devices or Equivalent
No.of
s 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: Z (When required by municipal policy.)
Work to Start: Qh 91 d 7 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 M' BOND ❑ OTHER ❑ (Specify:)
I cernfy,under the aims and pen ties of perjury,that the information on this application is true and complete.
FIRM NAME: ZIZar � S..l LIC.NO.: �Sy3-r9
Licensee. 4610 AAr 12 S✓( 4 /f-4 V-pd Signature LIC.NO.:
(If applicable enter"ex pt"in the 1'certse n nber line. J Bus.Tel.No.1 7 �� � �
Address: �d Xr�trs Ir //fit Alt.Tel No.:
*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:$
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/P lumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1.�0�`t4�� SC- 1,van es
Address: C) ,LerfIde
City/State/Zip: A ez4Ue►1 r 621SW Phone #:
i
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.g I am a sole proprietor or partner- listed on the attached sheet. t ? Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.�"Electrical repairs or additions
3.❑ 1 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'
comp. insurance required.] 13.[] Other
Any applicant 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 contractus 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 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 certifv under the pain and penalties of perjury that the information provided above is true and correct.
Sign ure: Date: 912010 -7
Phone#: (�1 $ I �/S—�6 7�0
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#:
Date.. .11 L. .... ..
NpRTM
pF ,pro ,ti0 i
a� ' TOWN OF NORF ANDOVER
t90PERMIT FOR GAS INSTALLATION
e D S <y Si1CHUEt ..
This certifies that . . . f�. �!�.l�.,�. . . . . .�?°� � . . . . . . . . . . . . . . .
has permission for gas installation . . !� c�l�ir '. . . . . . . . . .
in the buildings of . .�sk..4T .(.(y. . . .. . . . . . . . . . . . . . . . . . . . . . .
at . . ! en r7o... . . .. . . . . . . . . . . .. North Andover, Mass.
Fee. 31!. Lic. No../?. 1.?( . . . . . .
G�SINSPECTOR
Check#
6119
MASSACHUSEM UNIFORM APPUCATON FOR PO MIT TO DO GAS FITTING
(Type or print)
Date49
U
NORTH ANDOVER,MASS CH ETTS
lanl
Building Locations Permit# 6
ac- Owner's Name Amount$� � '4`/_
i
New D Renovation Replacement Plans Submitted
' I
�a Vj U
a
W W cyG C o Vi
Q �• aha rn � C d a O j O �
>
WW
Z W> UZ a > 0
SU B-BASEM ENT
IW, oW
B A S E M ENT
d 1ST. FLOOR
2ND. FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(Print or type) �--f
Name Check one: Certificate Installing Company
Corp.
Address bL
Partner.
1
Business Telephone _ M-�Q7 Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 13 No
If you have checked yes,please indicate the type coverage by checking the appropriate box.
Liability insurance policy M Other type of indemnityD Bond 13
Owner's Insurance Waiver:`l 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 1:1 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 p ormed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Sta G Code nd Ch er 42 of the General Laws.
i
By: nature of Licensed Plumber Or Gas Fitter
Title Plumber �t-470
City/Town Gas Fitter 8 (cense Number
rM Master
APPROVED(OFFICE USE ONLY) Journeyman
I