HomeMy WebLinkAboutBuilding Permit #996-2016 - Exception 3/24/2016*i)J� 44cW -� L�
Permit No#:
Date Issued:
LOCATI N
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Date Received
TANT: Applicant must complete all items on this
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PROPERTY OWNER s-r-c_-fi4At,)iE 4v`tR13) N6 -
Print 100 Year Structure yes (no
MAP PARCEL: ZONING DISTRICT: Historic District yes /no
Machine Shop Village yes 'G�
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
��_ne family
El Addition
0 Two or more family
[I Industrial
VAlteration
No. of units:
[i Commercial
El Repair, replacement
0 Assessory Bldg
0 Others:
0- Demolition
Other
El Septic 0 Well
El Floodplain 0 Wetlands
0 Watershed District
El Water/Sewer
DESCRIP] 1UN Ul- VVUKrx i u tsr- rr-mrviuvicu.
C—co M P 1--a-T—E 6 I,4,� R4,'V M 1'�4�MOD4-- 4—
Identification - Please Type or Print Clearly t-��O)A
OWNER: Name: 5Tr--F'HA-rJ/-F- 141KR) N)6=7_6'P'/ -:!�756 Ph'f-� Phone:,
A _j _j __ — - "? -'>/n A- v,3 T`� -*) If -,P R A Y P14r-5 3
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Contractor Name: 1�e� I_AV)6�F-01 tJ Phone:
E m a i 1: tlar N)5—' �" N,�?CAI 4DI tJ67— e 6-M A-1
Address: :713'5- L)+,4 -e -
Supervisor's Construction License:_c;-�Ci�?"�_ —Exp. Date:
Home Improvement License: /Z/ T170 —Exp. Date: -7
ARCH ITECT/ENGI NEER
Address:
Phone: '___
Req. No.
ocog
FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $ (Y)
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered cq1tra
,ptors do not have access to the guarantyfund
a.
V
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Location2l?�o
No.-cfiV 7o Date
I
Check # I
30151
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee
Other Permit Fee
TOTAL
Building Inspector
$QQ
$-
Plans Submitted [I Plans Waived 11 Certified Plot Plan 11 Stamped Plans F1
TYPE OF SEWERAGE DISP-OSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools [I
well El
Tobacco Sales El
Food Packaging/Sales [I
Private (septic tank, etc. El
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
Reviewed On Signature'.
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH
COMMENTS.
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No:
.Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
-,Conservation Decision: Comments
'Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
JF�:.: I R Ifffil s � - I . I - Z-- 1 't - , -. - " - lw- - - . - . - - � I- - r - - - - --- -- - - ----
,F, I R—E4 t, ENiTj
ca ed a" 65f� 9 W§
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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
DANGER ZONE LITERATURE: Yes
MGL Chapter 166 Section 21A—F and G min.sloo-sl000 fine
me
M
Doe.Building Pennit Revised 2014
r-/
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 1-11C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Engineering Affidavits for Engineered products
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 I
Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler P an And
Hydraulic Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
Engineering Affidavits for Engineered products
E: 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
4� Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
4 Copy of Contract
2012 IECC Energy code
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
Doe: Building Permit Revised 2014
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
$ 18,400.00
m
$ -
$
220.80
Plumbing Fee
$
27.60
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
27.60
Total fees collected
$
376.00
230 Andover Bypass
996-2016 on 3/24/2016
Bathroom Remodel
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795 Dale Street North Andover, MA 01845 (978) 686-3607
HIC#111990 FID#26-0816298
www.LangevinBuilding.com
Job Descfiption
Stephanie Harrington and Stephen Naroian
230 Andover Bypass
North Andover MA 0 1845
Bathroom Remodel
All necessary permits
Hall and stairway floor protection for the duration of the job
Complete lead safe demo down to the studs and subfloor
Rough plumbing -tub will remain in place and toilet location stays in place. Vanity
location will move to outside wall between windows
Old dresser will be modified to accept a drop in sink and serve as the vanity
Wiring as described in accompanying David Electric job description
New plywood subfloor and durock floor tile backer
Upgrade insulation in walls and ceiling to code
Blueboard and skim coat plaster on walls and ceiling with durock tile backer in the tub
area
Roof vent for ceiling fan and wall vent for dryer
Tile on floor and on tub walls ( allowing $5 per sq ft for the cost of tile)
Two fifteen light passage doors, laundry cabinet, door and window trim, wood panel
wainscoting approx. halfway up the walls, baseboard molding, and laundry shelving
V
plumbing and electrical work
All cleanup and trash removal
The cost of these items will not be included in this agreement: New sink and faucet, new
toilet, shower valve, and light fixtures
If you decide to replace the tub and add an adjacent linen closet, the added cost will be
$1000 plus the cost of the tub
If you choose electric radiant heat under the tile, the added cost will be $850
The electrical work calls for a 20 circuit sub panel but if it is determined that an entire
new electrical panel is needed the added cost will be $450
The cost of painting is not included
Signe,
t-7
o A- y
Signed
Date—
Date
� A-C� -)-
Homeowner Information
Contractor Information
Name ,It 6, V 6
,�AATjje pqKp
Company Name
V'4—� rQ & ye, 0 )At--)
)-.A waievj tj 0, R C -M ()jD f -1-i
Street Address (do not use a Post Office Box address)
Contractor/ Salesperson/ Owner Name
-2-30 At�jDovf--� gyf;4�-S-5
90Y3
City/Town State Zip Code
Business Address (must include a street address)
[Qoi�� Atjrovi,,-:� MA
77-5- PhAz ��T- tb- AoDck/4CA AAA o/2"
Daytime Phone. Evening- Phone
CiVrown State Zip Code
c� -7 -7 `/ 0c,05"'
'Mailing Address (Rdifferent frorri7ab7ove)
Business Phone I Federal Employer ID or S.S. Nur-nbiF—
Law requires that most home
improvement contractors have
Home Improvement Contractor Reg. Number
Expiration date
a valid registration number
j � 0
",b) b -7_
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessafy.)
sleE a-CrA
Required Permits - The following building permits are required
and will be secured by the contractor as the horneowner's agent:
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start and Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
Date when contractor will begin contracted work.
Pate when contracted woric will be substantially completed.
I otal Uontract Mce and Fayment Schedule C-)
The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of. L1001 0 —M
Payments will be made according to the following schedule:
$ /0 A
$ 000 by or upon completion of
$ _L_ or upon completion of
P /- A -5 nEA- i N Cv--
$ �LLlc-o upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special $ --M-MTMd-f0r
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ ------ Mrbu7md 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.
Subcontractors - The contractor agrees to be solely responsible for compl6tion. of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this aereement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless othel: wise 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.
• Make sure the contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
--- --- ----
3 C,
go
Address
Business Phone Federal Employer ID or S.S. Number
Home Improvement Contractor Reg.
Law requires that most home
improvement contractors have
a valid registration number I P I IJ -7
The Contractor agrees to do the following work for the Homeowner:
(Describe in detail the work to completed, specifying the type, brand, and grade of materials to be used, use additional sheets if necessa!y.)
`�OY'00,44E-71_—X YQ,6MoD6L_
10�,iISAS�E SIGE 11-cccmtolit�YINC- Tcng D6_-5ct9,)P-n0M
Required Permits - The following building permits are required
and will be secured by the contractor as the homeowner's agent:
(Owners who secure their own permits will be
excluded from the Guaranty Fund provisions of
MGL chapter 142A.)
Proposed Start and Completion Schedule - The following schedule will
be adhered to unless circumstances beyond the contractor's control arise
Date when contractor will begin contracted work.
,Date when contracted work will be substantially completed.
i utai --untract rrice anu. rayment bcneauie
The Contractor agrees to perform the work furnish the material and labor specified above for the total sum of: ?I L1000 0 11-1—M
Payments will be made according to the following schedule:
-5-0-9 57-/4rgT—
__4 C>CC) prict, or the cost of special order Items, whiche.-vor is greater)
$ 6 1, QQQ by -/-� or upon completion of
$ / or upon completion of
P /,A -.5 -rE-R- i N cr-
$ 14C�o upon completion of the contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction)
The following material/equipment must be special $ —Tl5VffTmd-fbr
ordered before the contracted work begins in order
to meet the completion schedule.(**) $ for
NOTES: Including all finance charges (*") Law requires that any deposit or down -payment required by the contractor before work begins may
not exceed thegreater 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.
Subcontractors - The contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this affeement
Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contract.
* Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear.
* Make sure the contractor has a valid Home "mrovernent Contractor -Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757.
* Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy of a "proof of insurance" document.
* Kmow your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the
contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not I ater than midnight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right.
DO NOT
Two identical copies o
Date
,GN THIS CONTRACT IF THERE ARE ANY -BLANK SPACES!!!
contract must be completed and signed. One copy should go to the hoineowner. The other copy should be kept by the contractor
Contfactor's S17arture
Date
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AC(:)90 CERTIFICATE OF LIABILITY INSURANCE 1-3777/"z
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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 CERTIMCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
F.—D—,t IS WAIVED, subject to
IMPORTANT- If the certificate holdeili an kDOITIONAL INSUW he policy(ios) must be andorsed. 0 SUBROGATION
the terms and conditions of the policy, caftin policies may require an endorsement. A statement an this certificate does not confer rights to the
Certificate holder- in lieu of such wdorsement(s), EdwardWHayrs
PRODUCER PHONE -3162 FA -4425
Hays insurance Agen;y Inc. (978)686 [at AX N : (978)689
36 Hawthorne Ave.
Methuen
INSURED
Robert D Langevin
796 Dale St
Ma 01844#
& Dedham Mutual Fire Insurance
North Andover Ma 01645 INSURER F: I I
COVERAGES CERTIFICATE NUMPP2. REVISION NUMBER:
THIS IS To QERTIPY THAT THE POLICIES OF INSURANCF LISTED BELOW HAVE BEEN ISSUED TO THE INSuAFD NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMeNT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AMRDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, WMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR
(TR TYPR 09 INSURANCE a 9 ME= LIMITS
01.59a. POUCYNUMBFR tm
1.000,000.
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X COMMERCIAL GENERAL LIABILITY
EACHOCCURRSNCE
RENTED
CLAIMS -MADE DOCCUR
100,000.
MISES (E-8 accurrpm)
Mr:;o OM (Any aft PeTM S 5-000'
A A R0514357A 10125/2015 10/25/2016
pERSO,4ALIADVINJUITY S 2,000,000,
GENERALAQ00GATE 5 2,000,000.
GEN'L AGGREGATE LIMIT APPLIES PER:
PRO- f7 LOC
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PRODUCTS - COMPIOP AGG % 2.000,000.
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AUTOMOBILE LIABILITY
(E2 MR1001)
BODILY IWURY (Per p~) S
ANY AU`T0
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BODILY INURY (Per somant) S
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DESCRIPTION OFOPE$tATIONSIL4ocAnONSIVE"ICLEB (ACOAD 101, Addruonalstemarks Schedule. maybe onectiedomoraspaw Iv reQUIred)
Carperitry
ATIf%Id
SHOULD ANY Of THE ABOVE or:SCrJBED POLICIES Be CANCELLEO BEFORE
THE; r-XPPATION DATE TRIERSOF. NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
RPOFOMON. All rights rewrved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
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The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Mu
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contrac.tors/Electricians/Plumbers
Applicant Information Please Print Legib
Name (Business/Organization/Individual): 'ROBC-Kl— LAV�CEVIIJ !�-JDCF A-
Address:_779"�__ DA4-f :5-r-
City/State/Zip: 0 0 A-rA
N ��)O V -,C—( '�,_ Phone#: '1 ? 9 tl,, 7(5� 3 !(o 7
Are you an employer? Check the appropriate box:
LEI I am a employer with 4. El I arn a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2 _7-�E in a sole proprietor or partner- Jisted on the attached sheet.
s s lip and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5.0 We are a corporation and its
required.] officers have exercised their
3. E_] I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. c. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. &-Rcmodeling
8. 'KDemolition
9. E] Building addition
10.n Electrical repairs or additions
I Ln Plumbing repairs or additions
12.E] Roof repairs
13.R Other
*Any Applicant that checks box# 1 must also fill out the section below showingtheir workers' compensation policy information.
t Homeowner's who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the n ame of the sub -contractors arid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob 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 forin 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 staternent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert under lie pains andpenaldes ofpeijuty that the information provided above is true and correct.
Si2nature: =-t- Date:
7 4?� 1�5- F t5' ' -3 6 0 -7
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 ajoint 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 perfon-nance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) narne(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partner * ships (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 pen -nit 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 sur&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 "Jo ' b Site Address" the applicant should write "all locations in — (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
Massachusetts Department of Public Safety
Board of Building Regulations and Standard's
License: CS -002685
Construction Supervisor
ROBERT M LANGEVIN
796 DALE STREET
NORTH ANDOVER MA 01845
COMmissioner zxpiration:
02/24/2018
Offie, If CI.I..er Affairs & Business Regulation
'ME IMPROVEMENT CONTRACTOR
t' �gegistration: -1-11990 Type:
V\ - Expiration: -.- --
LLC
ROBERT LANGEVIN BLDG &JREM&DING LLC.
7
ROBERT LANGEVIN-
795 DALE ST
N ANDOVER, MA 01845
Unders"retary
Date. . \A ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
K,
This certifies that �A ,0. ..............
has permission for gas installation
......................
in the buildings of .... ��C� .........................
at ... I ...... 1 N, or t I h. 'Andov Vra,
Fee. Lic. No..A!�75
GASINSPECTOR
Check #
MASSACHUSEYIS UNIUMMAPPUCATON FOR PERM TO DO GAS FfFHNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New 13 Renovation 1:1 Replacement 11
Date 0 IQQ ill
Permit #
0jr I baL r\ Amount $
Plans Submitt/d []
(Print or type)
Address
Business Telephone
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Intalling Company
Corp. 7 -
Partner.
Firni/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0- No 13
If you have checked Yes, please i icate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 1:1 Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent El
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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 -of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
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Gas Fitter License NumBer
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If you have checked Yes, please i icate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 1:1 Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
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Check one:
Signature of Owner or Owner's Agent Owner Agent El
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
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compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 -of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
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Gas Fitter License NumBer
Master
Journeyman
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