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HomeMy WebLinkAboutBuilding Permit #480-15 - Bingham Way 11/12/20140 t4ORTFI BUILDING PERMIT 0 TOWN OF NORTH ANDOVER 10 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: ///,&//y SSACHUS IMPORTANT: Applicant must complete all items on this page LOCATION 'pl- AL. vi. PROPERTY Ow F C/ rib es ho hf MARNO" oP V yes 7777. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential F1 New Building F1 One family F1 Addition [I Two or more family Ll Industrial F_.1 Alteration No. of units: 0 Commercial Li Repair, replacement U Assessory Bldg Others: 1_1 Demolition 1-1 Other El: Septic e 680 b*, t AJ6, --V&h ,District f' &10 w" l C4;�,Q Lz;'r ) NV LA -71 = /,,/ +> 6,4- L L, L OWNER: Name: Address 7, Ad"x t6' 9! 1 Identification Please Type or Print Clearly) _[ ones q 121,4-kiU"i 4,12 --Un )C I kIG 44 P WrAl !A6 ARCHITECT/ENGINEER ILA Phone: /414 Address: Ll /k -Reg. No. RA - FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. �—/'--�7 I--- Total Project Cost: $ FEE: $ Check No.: no Receipt No.: L7 J U NOTE: Persoh's"c_onturacting with unregistered contractors do not have access to the g ranty fund Signature:of Agent.er 6646rebf c /,Owb Location t p1� C, Date TOWN OF NORTH ANDOVER Certificate of Occupancy ' Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # /-x270 Building Inspector Plans Submitted Ele "yi'.lans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE'0F SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS Reviewed On Signature_ CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes t Planning Board Decision: Conservation Decision: Comments L Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 3_84 Osgood Street FIRE DEPARTMENT -Temp Dempster on site yes no Located at 124 Main Street Fire Departmentsjcnature/date COMMENTS c�0 mfr\d <u W OJ" r "o O'� O c�0 p cc 0 M.0 V W Z Q J a �� y cu Z 3 == Z N v J E Q. L y m a0+ _ N � I7 U) �+ O E ? E c Z 0 2 0 CL Cc E10 &- J i , D '' Z O ' -o0 o �~ N 0-0 > a Ci) 0 S O W Q E O v (D N C CO W W J aZ CL _. m cc o c F- _ Q L L 2 CL N I— o U)co m v m as uiW = '0— O O IL 0 = O .cn .Q O L 'E V V O W L- U) - y H t . Q 0 V > ti •N i `Iv •N 12 W O Eo o Z C O O .c � y •E m m CL C O �+ v Im O �oCL CL C Q O v_ J M �CL O C Z ci y 0 CLc CL U) 0 J QWCH = LL O m Nm t U \ O O LL aU..• N N U C1 N V7 (A Z Z O O Y -O 7 O LL L = O c' >' L U c LL d H Z z = J d t = O �' @ C LL O a Z H W J W t m O V dJ V) O LL O u a H l7 L : O cr O LL G oC Q. W InLUm 25 LL E 7 Co O Z al v Y (A Y 41 Q Y O E V) p cc 0 M.0 V W Z Q J a �� y cu Z 3 == Z N v J E Q. L y m a0+ _ N � I7 U) �+ O E ? E c Z 0 2 0 CL Cc E10 &- J i , D '' Z O ' -o0 o �~ N 0-0 > a Ci) 0 S O W Q E O v (D N C CO W W J aZ CL _. m cc o c F- _ Q L L 2 CL N I— o U)co m v m as uiW = '0— O O IL 0 = O .cn .Q O L 'E V V O W L- U) - y H t . Q 0 V > ti •N i `Iv •N 12 W O Eo o Z C O O .c � y •E m m CL C O �+ v Im O �oCL CL C Q O v_ J M �CL O C Z ci y 0 CLc CL U) 0 Name / Address Energy Services 4th Floor ABCD 178 Tremont Street Boston MA 02111 Air -Tight Weatherization LLC 9 Story Ave Beverly, MA 01915 Phone: 978-998-4684 Job Location 9 Bingham Way North North Andover MA Estimate Date Estimate # 10/19/2014 216 Project Description Qty Rate Total Attic sealing with two-part foam 84 84.00 7,056.00 R-49 unrestricted - settled cellulose 14,040 1.97 27,658.80 Weatherstrip w/Q-Ion or equal 130 51.00 6,630.00 Automatic Sweep 130 26.00 3,380.00 Qlon and Insulate Attic Hatch 12 67.00 804.00 Building Permits 1 552.00 552.00 Total $46,080.80 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Siiite 100 Boston, .MA 02114-2017 www mas&gov1dia Workers' Compensation Insurance Affidavit: General Businesses Api2ficant Information Please Print LcLyibl Business/Organization Naine: Address: - City/State/Ztip- Are you an employer? Check the appropriate box: 1. I am a employer with employees (fill and/ or part -t ime), 2.[:] 1 am a sole proprietor or partnership and have 110 employees working for me in any capacity. (No workers' corp. insurance required] 3. [1 We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. (No workers' comp. insurance required]" 4, rj We are a non-profit organization, staffed by volunteers, with no employees. [No workers* cornp. insurance rcq.] Phone K- Ut �f Business Type (required): 5. El Retail 6. El Rcstaurant/Bar/Eating Establishment 7. Office and/or Sales (incl, real estate, auto, etc.) 8. Non-profit 9. EJ Entertainment 10.0 Manufacturing I LE] Health Care 12.0 Other ............ Mi rilum aiso tit' 0111 the sec(foll below showing their workers' compensation policy 1--co"11,111.11 "If the corponitc officers have cxctnl)tcd themselves, but the corporation has other elliployces, a workers' compensation policy is required and such an organizzition should check box #1. I am an employer that is providing workers' coft7insation insurance for my employees. Beli)ivivillept)liqe,itif(irnoalit)ti. Insurance (,ompany Name:_ Q, Insurer's Address: "� 4 -�- f - f I City/State/Zip: v Policy # or ScIfins. Lie. Expiration Datc:-- �11 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required und cr Section 25A of M(ij. c. 152 can lead to the imposition of criminal penalties of fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine of up to 5250,00 a day against the violator. Be advised that a copy of this statement may be fbrNvardcd to the Officc of" Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains andpenallies of perjury %� .1, that the information pro vided above is true and correct. cvc 11 Offrcial 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. Licensing Board 5. Selectmen's office 6. Other Contact Person: w%v%v.niass.gov1di,,t Phone To Whom It May Concern: I, James Fortin, do authorize Douglas Cranford to act as my agent in the process of applying for building permits and other necessary documentation pursuant to the conduct of business by Air -Tight Weatherization LLC. oignture Date State of Massachusetts County C, 3 l tlA On this n c day of M" 20 , before me personally appeared Jwfs1` r , to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their free act and deed. Notary PublicZ. Print Name: -an - ��--- - My commission expires: HUM I a, 7A2 1 Notary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires March 19, $021 r _ \ J 1 (lJf 191/1?l fi>Zft1C((aL 3`fis 0/0— ItrGft';l fl.G' llf;3f't� �r Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 Type: LLC Expiration: 3/15/2016 Tr# 248557 AIR - TIGHT LLC. WEATI-IERAZATIQN JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 SCA 1 Ce 20!.4-0.111 Otricc of Consumer Affairs d Business Regulation ;'F1oME IMPROVEMENT CONTRACTOR $ ikegistration: 165640 Type: Expiration: 311512016 LLC t� AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 tJude rsecretary Update Address and return card. Mark reason for change. LJ� Address [] Renewal i I Employment L a 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 1.0 Park Plaza - Suite 5170 Boston, MA 02116 wot va id without signature 1 iv9assachusetis - Deu:lrtmen6 of Frrbl;c: a'ety �. Bo<1rr1 of Livaldiny Re-9u1atrlanw .1rri :>ta cizrr.t 0m%irunion,'tinctt. �r t.rcen5r'. CS -052576 III PINEKNOLL DR Beverly MA 0191' C;ontnlrr5t'A0 " 1010312015 Al �'� CERTIFICATE OF LIABILITY INSURANCE DATE1MM/2014 Y) 11/17/2014 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 MassPay Insurance Services, LLC 27 Garden Street, Unit 1B Danvers, MA01923 CONTACT Jacqueline Marie Melanson, CLCS PHONE FAX ac No t : (978) 7744338 X105 (A/C, No): (978) 7741318 ADDRESS: jacWe@philrichardinsurance.com INSURERS) AFFORDING COVERAGE NAIC # INSURER A: AmGUARDInsurance COmpary 42390 INSURED Air-TightWeatherization,LLC INSURER B: INSURER C : 9 Story Ave Beverly, MA 01915 INSURER D : COMMERCIAL GENERAL LIABILITY 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS -MADE F—I OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO -LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident)$ PPERTY DAMAGE $ RO Per accident NDN -OWNED HIRED AUTOS AUTOS UMBRELLA UAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITYORYLIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A AIWC576437 07/01/2014 07/01/2015 v/ WC STATU- OT HF ER — E.L. EACH ACCIDENT $ 1,000,000 E. L. DISEASE - EA EMPLOYEE $ 1,0W,060 If yes, describe under DESCRIPTION OF OPERATIONS below E. L. DISEASE -POLICY LIMIT $ 1000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Proof of Workers Compensation 9 Bingham Way North Andover. MA 01845 C:ANC:tLL.A 1 IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE da*J-U0 MRAW � @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD --^ AIRTIA OP ID: JD CERTIFICATE OF LIABILITY INSURANCE DATE(MM4/14 YY) 11/14/14 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 TGA Cross Insurance, Inc. 781-914-1000 NAME: Jill DeHetre 401 Edgewater Place, Suite 220 PHONEJC, , Ext): I81-914-1 -- — FAX No): 781-246-2601 Wakefield, MA 01880 E-MAIL t John Scanlon ADDRESS: 1dehetre across.com — e@ g —_ -- _ INSURED Air -Tight Weatherization, LLC 9 Story Ave. Beverly, MA 01915 INSURER(S) AFFORDING COVERAGE NAIC # _INSURER A: Arbella Protection Ins. Co. 141360 INSURER B: Arbella Mutual Ins. Co. 117000 INSURER C.: INSURER D : INSURERE: INSURER F: COVERAGES CERTIFICATE Nl1MRFR- RFVISIf)N NIIMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. North Andover, MA 01845 INSRTYPE OF INSURANCE ADDL'SUBRi POLICY EFF- � POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X I COMMERCIAL GENERAL LIABILITY 03/08/14 03/08/15 _ DAMAGES RENTED $ 1 OO,000 .8500046432 + , CLAIMS -MADE l X ,I OCCUR ' PREMISES (Ea occurrence) MED EXP (Any one person) $ _ 5,000 PERSONAL & ADV INJURY i_ $ 1,000,000 GENERAL AGGREGATE $ _ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 PRO- OT- POLICY X E LOC ! JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 A ANY AUTO 27088400004 03/08/14 03/08/15 BODILY INJURY (Per person) $ a ALL OWNED! X ' i AUTOS SCHEDULED AUTOS ;_ _ - BODILY INJURY (Per accident) i $ NON -OWNED X X; �' PROPERTY DAMAGE $ HIREDAUTOS AUTOS (Per accident)_ ___ ---------- $ X UMBRELLA LIAB II OCCUR 14600052930 EACH OCCURRENCE $ 2,000,000 B EXCESS LIAB X CLAIMS -MADE; 03/05/14 03/05/15 gGGREGATE $ 2,000,000 DED X RETENTION $ $ WORKERS COMPENSATION •'I WC STATU- OTH-' AND EMPLOYERS' LIABILITYY / N '1. TORY LIMITS . .. ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ I N / A -------- - - (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes describe under -- -- --- - - - DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ i i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CFRTIFICATF 1401 r)FR rAKIC1=1 I erinAl 9BINGHA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 9 Bingham, Way North g y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (1 -or department use ❑ Notified for pickup Call Email Date Time Contact Name - Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2014 P TYPE OR PRINT CLEARLY -1 - OWL -4 /'+T �11 4 -z' "? � 6'." otLae& MASSACHUSETV LINIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY JIMA DATE ny off— II PERMIT # lift 16k JOBSITE ADDRESS a �� OWNER'S NAME OWNER ADDRESS 1 TELF OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D NEW: M RENOVATION: ® REPLACEMENT: FIXTURES Z FLOOR- BSM 1 1 BATHTUB I CROSS CONNECTION DEVICE E DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM f _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f _ DEDICATED WATER RECYCLE SYSTEM f DISHWASHER =IF— IF— DRINKING DRINKING FOUNTAIN �I FOOD DISPOSER I FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY 1 ROOF DRAIN I SHOWER STALL SERVICE / MOP SINK TOILET URINAL _ 1 _f WA`OHING MACHINE CONNECTION r__I WATER HEATER ALL TYPES _I _ WATER PIPING I (- 2 1 3 1 4 1 5 0,14 h" RESIDENTIAL.2— PLANS SUBMITTED: YES ® NO INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirer IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATI LIABILITY INSURANCE POLICYFJ OTHER TYPE OF INDEMNITY n i OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance Massachusetts General Laws, and that my signature on this permit application waives this SIGNATURE OF OWNER OR AGENT LIP 1 14 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performedunder the permit issued for this application will be inin cot with al ent provis'on f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L I f, L I LICENSE # SIGNATURE IMP M JP Q CORPORATION Rf2ejPARTNERSHIP Q# i LLC COMPANY NAME !ADDRESS `�CC•-- CITY iy�t c_e.►i► ___.._. _ _ ) STATE ZIP G2.TEL FAXj CELL �EMAILL Q�e______-_ ..__C.�--_-------._ ..__.___.__._t__�_..---►-�c--.._.._._., tAo,o e, t- �-A o-;� , ,tea,! e--�e,,p 51 1 li4 or z V1 ❑ H LLI a ui w LL (41W J44 4� q_z_ ` MASSACHUMM AIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ... — CITY _ _� �- MA DATE a ( ( PERMIT # JOBSITE ADDRESS v „ �� OWNER'S NAME .� POWNER ADDRESS I TEL --FAX 1 7-1 TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL:6. — PRINT CLEARLY NEW: RENOVATION: Q REPLACEMENT: Of PLANS SUBMITTED: YES ® NOQ FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! j f i - _ I — ___a 1 .__T._! _�_f __._._� ---I _J DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _f _-__...5 _-__-. ___.__. f ._ _1 _ i _.__—! --.----i •___---F ..._.---I -.._-.- ----.-_.3 __._.._ _ _..--_! FOOD DISPOSER FLOOR/AREADRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK --I J `� __f LAVATORY ROOF DRAIN ; _ I � _ ! _ .__ f f -.---- (__-_._j SHOWER STALL _.____1 SERVICE /MOP SINK __._j---__( _^__ ! ____ [ __..`! ____j E. _-_f __._.__I ____ __� _ _i E—A TOILET URINAL WA`�`yIINGMACHINE CONNECTION 1 WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ,,...; NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY Q BOND P OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 01 AGENT In— QSIGNATURE SIGNATUREOF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in in co�with all Pert' ent provi 'on f the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �'`1'{2-�L �L (LICENSE # ,'Z� I SIGNATURE IMP M-- JP []I CORPORATION �PARTNERSHIP P# LLC COMPANY NAME %%t 1, ADDRESS CITY I WVt k n5&7 ; STATE �� ZIP ':�Z --�VLTEL -- - FAX— I CELL EMAIL I ,, c.:,r>- e__ Ot "t . w e--)0wp 5-1 tl 1 14 or -I z N ❑ E; 10277 This certifies that ...... A .A -(I- ( .L , (--) Z " - "^.j \ k ................................................. Date.A�V6........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform. ,4Z -1o, � e 1-> 4L -Skk�, t,,� A .............................................. : ...... plumbing in the buildings � (, -�- .......... .... 5 Z ... 1. . 0 A \A%A� .... �-c Andover, Mass. Fee .4.2.6 .... u ... Lic. No. ................. . .................................................. .... .. .... ... ..... ......... PLUMBING INSPECTOR Check # 1 The Commonwealth of Massachusetts - Department of IndustrialAccidihts Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information % Please Print Leafty Name (Business/Organization/Individual): K1 -7T— &_e4 .Jo 6 1 Address:-�-- .--c7 City/State/Zil v,,c - We- Phone #: 7 -Y/ —&670 !� J Are you an employer? Check the appropriate box: .1 -El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.Oam a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3.01 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other .A t *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they aie doing all work and then 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 workerevcompensation insurance for my employees. Below is the policy and job site information. j Insurance Company Name:. ?_Vov � CJrt � L1 Policy # or Self -ins. Lic. #: % Expiration Date: Job Site Address: W, -)k( -C / lY"1�t'"^ �C� City/State/Zip: d6Li,ef cj/eA,-4 4-/ 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 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. Ido Izerebcert under the pains and penalt' ofperjury tlza he information provided above is true and correct. S i2n ature: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, 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 NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 6.00 Washington. Street Boston, MA, 02111 Tel, # 617-7274900 eyt 406 or 1-877:MASSAk'B Revised 5-26-05 Fax # 617-727-7749 WWW-mass.govfdia z 1e ms, Maura From: Joanne Comerford [JComerford@northandoverha.com] Sent: Tuesday, November 19, 2013 3:54 PM To: Deems, Maura Subject: RE: Permit Hi Maura, There are 4 tenant buildings and a community building at Bingham Way and there are 7 tenant buildings and a community building at Fountain Drive. The total buildings that work was done in is 11 because the toilets were not changed in the community buildings. The actual toilet count was 42 toilets and 42 showerheads at Bingham Way and 40 toilets and 40 showerheads at Fountain Drive. Thank you for your assistance. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 6comerford@northandoverha.com From: Deems, Maura [ma iIto: mdeems0)townofnorthandover.com] Sent: Monday, November 18, 2013 11:17 AM To: Joanne Comerford Subject: RE: Permit Joanne, One last question, how many buildings on Bingham and how many buildings on Fountain? Thanks, Maura From: Joanne Comerford [mailto:JComerfordCabnorthandoverha.com] Sent: Friday, November 15, 2013 11:57 AM To: Deems, Maura Subject: Permit Hi Maura, I just spoke with the contractor and he said he left a check with you without the amount filled in so you can fill the correct amount in based on the 82 toilets and showerheads, which should be $740.00. I apologize for the confusion. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 1 icomerford@northandoverha.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. Deems, Maura From: Joanne Comerford [JComerford@northandoverha.com] Sent: Tuesday, November 05, 2013 3:08 PM To: Deems, Maura Subject: FW: Project #196031 North Andover Housing Authority Good Afternoon Maura, Please see the information in the email below regarding the permit cost that you gave to me months back for the Toilet & Showerhead Project at Fountain Drive and Bingham Way. If you have any questions, please do not hesitate to contact me. I appreciate your assistance. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 jcomerford@northandoverha.com From: Joanne Comerford Sent: Tuesday, October 22, 2013 10:45 AM To: Sherry Modestino (smodest(&comcast.net) Subject: Project #196031 North Andover Housing Authority Good Morning Sherry, (�- �,o-ek ? Could you please let Mark Getchel know that Maura Deems, Department Assistant at the Town of North Andover Building Department gave me a price of $740.00 as the cost for the Permit for the Installation of Water Efficient Toilet and Showerhead Project that will begin at Fou tain Drive and Bingharp Way on ovember 5th. lio 40 1It��-� 1 e The breakdown that Maura gave me for the cost of the Permit is as follows: 82 toilets - $2.50 per toilet = $205.00 82 showerheads - $2.50 per showerhead = $205.00 11 buildings @ $30.00 per building = $330.00 Total Cost $740.00 If you have any questions, please do not hesitate to contact me. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 �o 0"-J N� VV1, (�- W2, P' - Fax: 978-794-1142 jcomerford@northandoverha.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 2 'Deems, Maura From: Joanne Comerford [JComerford@northandoverha.com] Sent: Friday, November 15, 2013 11:57 AM To: Deems, Maura Subject: Permit Hi Maura, I just spoke with the contractor and he said he left a check with you without the amount filled in so you can fill the correct amount in based on the 82 toilets and showerheads, which should be $740.00. I apologize for the confusion. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 icomerfordPnorthandoverha.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. I'lo!'3. %19 X Deems, Maura From: Joanne Comerford [JComerford@northandoverha.com] Sent: Friday, November 15, 2013 11:50 AM To: Deems, Maura Subject: FW: Project #196031 North Andover Housing Authority Hi Maura, I apologize for not getting back in touch with you regarding the total amount of toilets and showerheads being installed at Bingham Way and Fountain Drive. The correct amounts are listed in the email below. I will call the contractor and ask that he get back in touch with you immediately so the amount paid can be corrected. Thanks so much for your assistance. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 icomerford@northandoverha.com From: Joanne Comerford Sent: Tuesday, October 22, 2013 10:45 AM To: Sherry Modestino (smodest0comcast.net) Subject: Project #196031 North Andover Housing Authority Good Morning Sherry, Could you please let Mark Getchel know that Maura Deems, Department Assistant at the Town of North Andover Building Department gave me a price of $740.00 as the cost for the Permit for the Installation of Water Efficient Toilet and Showerhead Project that will begin at Fountain Drive and Bingham Way on November 5th. The breakdown that Maura gave me for the cost of the Permit is as follows: 82 toilets - $2.50 per toilet = $205.00 82 showerheads - $2.50 per showerhead = $205.00 11 buildings @ $30.00 per building = $330.00 Total Cost $740.00 If you have any questions, please do not hesitate to contact me. Best regards, Joanne Comerford, PHM Executive Director 978-682-3932 Ext. 11 Fax: 978-794-1142 icomerford@northandoverha.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. Date...........l.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...................................(,.......................1...(........... �.. ......... has permission to perform ......... ....t= ......... ...:�..��i�l...�C........................ wiring in the building of..........Tfv#4..............!`�(..�L%S at .......�....... �. ��.......1. u. A:�....... JAS .... , North Andover, Mass. Fee..../. .......... Lic. No... .......(.... .......... .~L.. ................. ELECTRICAL INSPECTCgR � Check # � C- U 1 2-`'i :y Ar Commonwea& of M7aijac"tb Official Use Only 2epartment ol._iire Service] Permit No. Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 Cleave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: % - S - ,gyp/Y City or Town of: i//�e ,�,�,�pot•� 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) _/- Owner or Tenant 6 ,f K I,, Owner's Address 4 "Inat" m 'I'l-aw s ",4/?LII, g. , Is this permit in conjunction with a building permit? Yes ❑ No M Telephone No. yD 35.?,`), (Check Appropriate Box) Purpose of Building t h�y�,�ey SPdvjf C,4Z Utility Authorization No. Existing Service Amps (Volts Overhead Undgrd ❑ New Service Amps Number of Feeders and Ampacity Volts Overhead ❑ Undgrd ❑ Location and Nature of Proposed Electrical Work: No. of Meters 12 No. of Meters Completion of the following table maybe waived by the In ector 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 Swimming Pool Above ❑In- ❑ rnd. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets 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. Total Tons g No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons J.KWNo. of Self -Contained Detection/Alerting Devices No. of Dishwashers g S ace/Area Heating p b KW Municipal Local ❑ Connection [I Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts I Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TEquivalent Wiring: No. of. Devices or 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: t G LIC. NO.: Licensee: ^t e- 6�A�llmeyVp Signature LIC. NO.: (If applicable, enter "exempt" in th license n tuber me Bus. Tel. No.: Address: 1' �� 4 &,c li!25 e /� ,�% �' 1.�� Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. pe