Loading...
HomeMy WebLinkAboutBuilding Permit #810 - 80 PATTON LANE 5/24/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: & ( 0 Date Received . .ft a i 7-1% TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building jrOne family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other } ❑ISeptic DWe:ll1Fl oodplain) 01Netlands .. 0� Watershedj_®istnct DESCRIPTION OF WORK TO rpt NtKruKivitU: Identification Please Type or Print Clearly) OWNER: Name: /tr Acil,y_r Phone: l 7 `Co %Ci_C"� � Ar4rtr000• lIUU I GJJ. }} i.CO.N Supervisorrs�Construction�Llcens_e ;:_ �,3�_� Exp; "®a"te , _ .�/! %�.�_!�_� _ }� Homlmp[ovement Licensex. Dated 12e ARCHITECT/ENGINEER Address Phone: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASO N $125.00 PER S.F. Total Project Cost: $ f 3�b ' - / t FEE: Check No.: 19 5�0 Receipt No.: Gulp 4 NOTE: Persons contracting 4ith unregistered contractors do not have access to the guaranty fund e Signature sof Agerit/Owner _: _.._, . 1 S�gnature:of contractor.. Plans Submitted F1 Plans Waived ❑ Certified Plot Plan ❑ Stam d Plans ❑ Building Department The following is a list of the required forms to be filled out for the appropriate. permit to be obtained. R.00firig, 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 o 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 app. al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording trust be submitted with the building application Doc: Doc.Bui!ding permit Revised 2012 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan Stamped Plans THE FOLLOWING SECTIONS FOR DPhCE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ [] COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature ;COMMENTS o:C Zoning Board of Appeals: Variance, Petition No: Zoning Decisionlreceipt submitted yes 0 Planning Board Decision: Comments Co.-hservation Decision: Comments WR,ter & Sewer Connection/Signature Date Driveway Permit DPW Toivz Engineer: Signature: Located 384 Osgood Street `FIRE DEPARTI!lIBNT -Temp Dumpster on site yes no Located at -124 Main Street Fire tihefit,gighattirb/d6t6i/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 Top 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 Location B �GtA L,.,j No.—,E to — t 3 Date Check # 1 26440 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �o� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 1 r Building Inspector May 24 2013 16:54:55 1-055-093-4357 -> BIE NOT FWD Comm Lin Page 664 s'� _- _ DATE iMM/DOIYYYY) � CERTIFICATE OF LIABILITY INSURANCE k045 05-24-201.3 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMAlIVELYOR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATEOF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If, the cortificrato holder it; an ADDITIONALINSURED, t:he I)olicy(iLss) rnuµt ba endorsed. If SUBROGATIONIS WAIVED, subjoct to the torrtls and conditions of the policy, certein policies may requlrs an andorgomont. A Stat'.ornant on t'hit, cwti'ficAto dclos riot confnr rightg to tho crarti'finrate holder in lieu of such endorhumrant(s). PRnaucfR AA(cNnF.xr „�„S66)4E7-8710 Ar,Nn). (8,_,)__0..H_-54, EASTERN INSURANCE Ca'ROCTP LLC/PHS "e�� O � r, r 08-7059 P. (8 5 6) 4 6 7- 8 '7 'i 0?.(800)308-5459 � �_...__1._......1.__.__.__...._....._......_—.._._..-. ---- MALI. 303. WOODS PARK DRIVE ADDRESS: .............. .._-.�.._....... —.— _._........_ CLINTON NY 13333 IN,auIiLFtI5lntPaRrnNGCOVERAGE NAIC9 INSURERA: H,11^t:f•Ord T'7.YE-' fns CO INSW EL) IN€UR�R CI JOAN BEARDSLEY DBA JB PRESERVATION INSURER C CARPENTRY . NS ...uRER D . ... 48B BAY STATE RD__--....._._..-- NORTH ANDOVER MA 01845 IN:'iUR@R INSURER F ; COVERAGES CERTIFICATE NUMBER; hI=V151UI\J NUIVlbttr: THIS _ _ 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEENµ ISSUED TO THF INSURED NAMED ADOVF.. 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 1*rHE POLICIES DESCRIBED HEREIN IS SUBJECT 'T'0 ALI- THE TERMS, F,XCLLISIONS AND CONDITIONS Or aLICH f OLICIF.S, LIMIT;; SHOWN MAY HAVE OEF.,N RC;Duc: ,D OY PAID CLAIMS. ��SY '.�iq»�YY Yi�ID0 ” y "� _ ijY1YT� }t " - !TR TYPE OF /NSURANCE .......... PnLIGV NUMFER ,,,,,,,,,,,,,, ,,, ,,/MM/00/YVYVI IWITS /MM/AOIYVYYI,,,,,,.,,.,,.,,,,,,,,,,,,,,,,,,,..............., GENERAL L/AR/L/TV EJPr,rl r)r'r`IJt RENO r;: P 0 O 0 O 0...... 1S�rvYA7;i"i3i �1'iJ"iCLS-- 0 0 000 '; COMMERCIAL GENERAL LIABILITY F't4[ MISF.S_ LFh 2 x'11EVilcul s3 CLAIMS -MADE X i OCCUIa MED EXP (Anv, non person) 5 10 � 000 X General Li. --1 � SBM PL5490 08�/ C)^ 03 01:1 /= O<^ 03 01.4 i F'EtISONAL. & AC1V INJUIVY / /- y rV('EWNAI, AIi Cv Rt;(iAT'% _ t2 0000.00 �: C.EN'L A(XGRE( . 1.11',AIT AP.1'.L,I.GS PER: ; PRODUCTS r-:OMPMP AGG 2 0 0 01 �� O 0. _A �.. tA71as I._n.! I......___ -- _ POLI CY _L.(J (:_ i ...__.__—.._....-___. J[(;T_ —._ _____..--....___—_..___ -------- .—_....._._—_......._____—._...... AUTOMON/!E 40614I7Y (;9MBINEf,) ',INC—LF, LIMIT � (t'n nanldenq BODILY INJURY (Pei DW861'II 6 ANY AUTO _.. .._..... .._ E ALLOWNE.O ; „7CFiEDU1.E;D I" -II L. J_......._.._...-_ ..................'i.r,u.u._�nt(...4 BODILY INJURY (P• � ide __......_.....___.._......_.._ AUTI)ti �.... �,i AUTO,`) PROPt'STY DAMAGE HIRED AUTOS NON -OWNED (Por .n;cidr:nd ---•••••i AUTOS F UMIiREI.lA !/Ad C ;..—.....,. _....... (; C.UFiRENC .E..._....... ? fXCf5s LIAR— -' _ CLAIMS MADE AGGRF:GA IE Uf:O REY'liNl'Ic,7N 5 5 WORNERSCOMPENSAT/ON ; WC 5TATU OTI, ANO f44P40Vf'RS- 0A(Jl!l1YY IN ANY PFt0PRIE'fUR4TARTNERftiXECU'1'IVEiY : (� NIA L. Eh(=EIA(:L;;IgtN'I' ^-----•-----•----..._..-------- y OE'P'ICT14lMP:M[iEiREXCLUDED7 juandorory Jn N1Y1 E.L.. DI F.A,:>E EA EMPIOVF:' B II Yes), r90s8rn)a moor DESr:RIPTION OI- I;)PE.RAnriN%,7 I:u)iow L".L. DISEASE POLICY LIMIT 0 more NPOCO Those usual to the Insured' s Operat.i..ons . P`;ZRTIGIr'ATG 1-IrII 171GR ('ANCFI I ATION ' 7 tIdd-[U1U AUUML) L UroIUNA I IUN. Call ngnts reserved. ACORD 25 (2010/05) Tho ACORD name and logo are rogistarod marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEl'ORE THE; EXPIRATION DATE THFREOF, NOTICE WILL BEI TOWTI of North Andover DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUMOR/PED R£PRESENIATWE 120 MAIN S" T NORTH ANDOVER, MA 01845 7a­r- ' 7 tIdd-[U1U AUUML) L UroIUNA I IUN. Call ngnts reserved. ACORD 25 (2010/05) Tho ACORD name and logo are rogistarod marks of ACORD May 24 2013 10:56:32 1-055-893-4357 -> BIE NOT FWD Comm Lin Page 006 CERTIFICATE OF LIABILITY INSURANCE R°^�� DATE IMM/pl)LYYYYI_� 05-24-2013 THIS CERTIFICATEIS ISSUED AS A MAT"T"ER OF INFORMATION ONLY AND CONFERS NO RIGH"T"S 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, tho c©rtificr.ite holdor IA ;u) ADDITIONALINSURCD, f:11t3 f)f.)Ilfy(IFS) m1.14t'. be Endorsed. If SUBROGATIONIS WAIVED, sl.ihjott to the tefrT)A And Conditiony of tho policy, cortaln policieH may feC`)ulrR an andorsomont. A Stalt..?morit. on L'hl£; cort'.i'flcate docs riot con'for right'E3 to 010 corti'ficate holder In lieu of Such ondorF;OrnantW, CONTACT PROPUCER EASTERN INSURANCE GROUP LLC/PHS 6_111"',-- ,,-,.-,-,,-,-,,,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,_.,,,,,,,,,,.,.,,,,,,,,,,,.,,,,,,,, ,.............. „ N�AM1M_AEII: (aGG)4673730 oC_ ?8 - �.4 5 V % 0 J P. ij 7 ^ % 3 O F 0 0) 3 ) " y _..__ 101 WOODS PARKDRIVE , ADDRESS: __._.......-•------...._--..`----._.-_...._.._. _.__..... _...---'�'_--_--- IPJ5LIRER(:a1 AFFORDING COVERAGE NAIL N CLINTONNY 13323 ...............-........._...................................................................................... ............................. INSt1RERA: I3,-i1"t:{ord Fisc, I.n&- Co lNStlA'FA INFIJRGR FJ __... JOHN BEARDSLEY DEA JB PRESERVATION _._................ _._........ - ...... _—._._...— INSURER SUIiER C _ARPENTRY INSl1RER D - 48B BAY STATE RD _..___..__..._- I1--.114ca � . NOR'T'H ANDOVER MA 018 4 5 INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: _ THIS IS TO CERTIFY THAT THF.. POLICIES OF INSURANCE LISTED BELOW HAVE BF91SSUED 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 T'O ALL THE TERMS, CXCIAISIONS AND CONDITIONS Or SUCH POLICIES, LIMIT; SHOWN MAY HAVE DEEN RFDUC. D f3Y PAID C'LAIM5, ,,,,.,„ . V7h' Gff lMpVIlM/A4/YYLrnrrs TYPE OF INSURANfE PO((GVNUMAfR V -g - GENERAL LIABILITY f AChi r)t:r)tJriftFNCf P , _00 0 L O COMMERCIAL GENERAL LIABILITY N(IL_MISF.. ,LF,p........ 000 1 R CLAIMS -MADE X OCCUR MED EXP lAnv nnclu:rvcrn_ ......._. _ Li zab i r, r3 2/ /203.3 02/0:;/2014'; PE(woNAL m„AoV INCL (A LJ I,,,,,,,,I ^DN: r.• r..a •i o o a^ n 3 0 GCRWAy'E: s O U 0 000 CaFNY:HA6__-- A�__._._— r P G 1 , QkN'L ,AGGGRF.,QA7T . I.IMrr AI'1aLJ.G5 PFR: _PITDnucT._ r..DMP1O_ AG _ e 00 0 _ 0 (� 0_ 1 I X ;Pan. —! LILY ..........: ,t 'EST ......__, L.G ....�:.__._._......_.__—._.....___.._.:_......._._......__-__..........._ g PC .___......._.--_.___ AUTOMOPILF 4/A6I4/rY I (:gMBIN(;GT 51NC;1„F l,IM1T lt'n noahlcnq i BODILY INJURY (Pili 01'.186111 ANYAUTO - BODILY INJURY (Pier accldm) ¢ E ALL. OWNED '- �ccF1FDlJLEO i _____._ ... ......... ..... __..__..___ _..----• .......... AUTOS „i AUTOS """''' `", IyriLJPf::IT'I'•Y L).AMAGF ...g HIRED AUTO, NON -OWNED (Prx>s:cidwitj -- Al)TOj 6 ; UMBRFLLA LIASi EACH Qr;d:LtRRFNt;E............. ....... . OCCUR �..... _ fXCf55LlAB i CLAIMS MADE; Al3GREGATE - _ n rT� UEf7 FtEY'tNIILJN 5 b WORKERS COMPENSAT/ON WCSTA'rlJ IIC7111 ANO EMP{OVERS'VAH/L/TY YIN S?CIY.,kTMA?,� ANY rROPriIETORIPARTNEfi/L'.XECCITIVE ---- f "' F L. EACH A('-(:II)E'N)' OFrICERiM1Iv1BER EXCLUDE Di NIA ^--- -- -- --- — --- (AfondarorV In NH) �-E.L. DISEASE EA EMPLOYEE. k, 11 YBrs;, t)Ls�Cfll)g unow DE:iCHIP TTION OF OPERArlf,)N ruilolN ; E.L. DISEASE POLICY LIMIT 0 Ej I -----"-----_...._....------..-........--........ ... .......... ---.._..---'- ---..__.._----.._..__..___._._..._....--'------......_ GESCRIPT/ON OF OPERA BONS I LOCATIONS / VENICLES /Arrach ACORO f 0 f, Addrtiann! Rrmnrks Schaduln, N maro vpaco is rapunad) Those u. ua:L to the Insured' s Operat..ons . _ - -- rnwlrt•'1 1 nTlllwl V L�111'IVF11L - - --- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED EIEFORE 'THE; EXPIRATION OATF THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Town O North Andover AWHOM&D RfPRESENTAVVE w.... 120 MAIN ST NORTH ANDOVER, MA 01845 0 1988-2010 ACORD CORPORATION. All nght's reserved. ACORD 25 (2010/05) The ACORD name and logo are registarod marks of ACORD Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 14,000.00 m $ - $ 168.00 Plumbing Fee $ 21.00 Gas Fee 100 comm. $ 10.0..0.0 Electrical Fee $ 21.00 Total fees collected $ 310.00 80 Patton Lane 810-13 on 5/24/2013 Master Bath Remodel CO) m X m X m CO) mm v C � 0 O CD 0 Z N p 0-0 CLO co V1 -a o 0 CD C� = cr CD O ou CD CO CD N• CO• C ' � v a z n O CCD O CD O ti. z m cn O C7 C z z I O ;U- m —I -v cn z Z cn < 0 O •a ; 3 O O 2 0 NcCD -0 y —Di =-CDC m Z p _? !7Zin O N .�-r lD y h0 O C O m .-r al CD Cl) m CD N WOV - ce 2 1 3 O 7 co Q. O .+ U) O p G1 Cm) WCD O' 0< cc O N CD.. Z CD C O 0, a as ��� c U 0 N � C.�. < Q_ s CD" o (A na)< .-� CD �CD S SU '0 rt O y at! O o n - 1 in O �a O• � O ' CD P N CD CD 3 s 1' =r nom' '� C CD V fD 0 su o CL - vs VI OC O N rD - o co 3 f m m v Z T 7p aqq S(D H _ Z m -i T w VI Z. 70 M ? m m ; n D Z M n 0 T - �o D=q S C W cZi Z •o m 0 m S T 3 0 p W C p zrn Z LA m 0 0 n LA (D 3 T Q - n s M ' v O '� m D x S The Commonwealth of Massachusetts Department of IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Buil.ders/Contractors/ElectriciansTlumbers Applicant Information Please Print Le�ibiy Name (BusinesslOrgani''zation4ndividual)' :4,4 6 t' ,-, Address: 6 LL City/State/Zip: ep, Phone #: 174 V3 Are you an employer? Check the appropriate box: - Typo of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hiredthe sub -contractors 7• [ Remodeling 2. Z I am a sole proprietor or partner- ship and'have no employees listed on the attached sheet. These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. D.Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner -doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), andwehaveno 12,QRoofrepairs insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required.] "Any applicant that checks box41 must also fill outthe section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they tie 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 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. 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 requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as wellas 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under Aepains andpenalties ofper, jury Aat the information provided above is true and correct. 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): 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 "...everyperson in the service of another under any contract ofhire,- 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented tothe 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 phonenumber(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 maybe 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 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 NOTrequired 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 anal fax number. The Gowmonwealtf ofM-0machuseits Department of Jndustdal ,A,ccldouts Woe dwestigations 600 Washiragtoa Street Boston 02111 TO, # 61.7-727-4900 ext406 or 1.-8,77:;MASSAFB Revised 5-26-05 Fax # 617"727-7749 1Massa- "Se-S Construction superl3tiuS- _ CS-088368 JOHN W BEARDSLEY r° 9 LOWELL ST ANDOVER MA 01810 `` Y 03/17/2014 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration JOHN BEARDSLEY JOHN BEARDSLEY 9 LOWELL ST ANDOVER, MA 01810 sC.A 1 20M-05111 __Office of Consumer Affairs & Business Regulation =iHfl'ME IMPROVEMENT CONTRACTOR registration: 146678 Type: Ex iration: 5/10/2015 Individual JOHN BEARDSLEY JOHN BEARDSLEY 9 LOWELL ST.— ANDOVER, MA 01810 Undersecretary Registration: 146678 Type: Individual Expiration: 5/10/2015 Tr# 240569 Update Address and return card. Mark reason for change. Address` �: Renewal Jj Employment Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 C/ Not valid without signat re i / Contract for master bath renovation- 80 Patton Lane. North Andover, MA 5/20/13 Contract to: Mark Palmer 80 Patton Ln. North Andover, MA 01845 Contract From: John Beardsley 9 Lowell St. Andover, MA 01810 CS# 88368 Cell # (978) 973-2854 - Renovate existing master bathroom. Demo existing tile and shower unit, replace fixture and surfaces with new cast iron tub with tile surround and tile wainscoating on walls 4' AFF +/-. Save walls above the and ceiling. 1. Carpentry- demo existing master bathroom the and existing fiberglass tub and shower - new the backer. Install new vanity(labor), install bath fixtures(holder, towel bar, mirror, ect.) install vent for two bath fans. $50/hr + 10% of material and subcontracts- estimated +$2500-$3000 + 10% including material, permit fee. 2. Plumbing- plumber to install new toilet, vanity sink/faucet, cast iron tub, valve and drain(labor) $3900 includes new cast iron tub 3. Tile- labor for tile installation, 4' AFF + tub alcove walls, Bullnose cut on edge. Approx. 200SF. $2000-$2200 4. Electric- install new mid range fan with light in shower, install new GFI in existing whirlpool circuit(to be remover) install new light fixtures (2) and replace or remove broken fan timer switch. Install new mid-range fan/light in 2nd bathroom and GFI $1375 5. Paint- paint ceiling, door, trim, ect. $400-$500 6. Allowances +/- A. vanity with top/sink or $600 b. Toilet, faucet and tub/shower valve. Bath accessories /.0 r� $500-$700 Total: $11,500 - $12,500 +10% Payment schedule: $3000 at start $4000 ready for tile Balance at completion Acce tance of contract and payment schedule, John Beardsley