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Home My WebLink AboutMiscellaneous - 1 Village Green9742 Date ..... — / 0 ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...................... e4<1e.41"F ...... . ........ ....................... has permission to perform ..... ....... wiring in the building of ...... at... ..Co ..... .. ....... ...................... // ... ..... Andover, Mass. Fee .... �-5— Lic. No..J ... Nkf'/! ......... &��iECTO;V iACTRIcA�L INSPE R Check# 716'0�7 Commonweal of Ma-mackajetti Official Use Only 2epartment o f }ire Services Permit No. ! 7 Z Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave 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: October 29, 2010 City or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1 Village Green Drive Owner or Tenant Village Green Telephone No. (978)683-4101 Owner's Address c/o Property Management of Andover. Is this permit in conjunction with a building permit? Yes ❑ No ❑x (Check Appropriate Box) Purpose of Building Residential . Utility Authorization No. Existing Service Amps / Volts Overhead ❑ . Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Jump water meters and drive ground rods in (11) buildings as needed Comnletinn. ofthr fnllnwina tnhh, mm; ho mini—d Al the (wi— 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 [:i In- ❑ rnd. arnd. o. o Emergency Lighting Batter 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 No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number " "'""'. Tons ..""'. KW """ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local Municipal ❑ Connection ❑Other No. of Dryers No. of Water KW Heaters Heating Appliances KW No. of No. of Signs Ballasts No. of Security Systems: * Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent al OTHER: Attach additional detail if desired, or as required by the Inspector of Hires. 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 ❑x BOND ❑ OTHER ❑ (Specify:) 1 certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Crowe & Sons Electrical Corp. LIC. NO.: 17168A Licensee: James B. Crowe Signature LIC. NO.: 1 (If applicable, enter "exempt " in the license number line.) Bus. Tel. No.: 978 453-6696 Address: 576 Middlesex Street, Lowell, MA 01851 Alt. Tel. No.: 978 251-8573 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001051 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent . Signature Telephone No. PERMIT FEE. $ 125.00 i5�u "e -P ,O� /-//- //-/ ) A" F 4� Date .... 1. 1.. - / 5 - 7 ....................... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that .......... C ..... R..P. ... cP .... C Zl-� e,011P F ................................ has permission to perform .... S.'Ckgz ...... & wiring in the building of ..... 0-5�'( . . ...................................................... at ........ ....... ...................... . North Andover, Mass. FeeJT'-0�'!:'—... Lic. No. 1.7.1.tff'# ............ Check # YwO 7 7 7796 Date. -3. 9249 TOWN OF NORTH ANDOVER O's imawim 0 PERMIT FOR PLUMBING SACHUS This certifies that ......................................... -r has permission to perform j'Mt'- ................ V,Z,(" d -A plumbing in the buildings of ....... ........................... at 6�wo .&, Yr 46 P ......... ........ North Andover, Mass. Fee.��'--5.�Y . Lic. No../j1t*/* 41: PLUMBING INSPECTOR Check # 17?-'? / MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location_ `�,��,��, \�' � 7�1,�.-�. �J ��C� Cj,�oszrn�r\��o� Date Permit # Owner ,\\Cj2 (Vr-ua� (s) -AQ ASS�)- tv Amount New Renovation Replacement ® Plans Submitted Yes rl No Ti'TI'TTTi��o (Print or tom) �LCheck one: Installing Company Name sc"vl C e Address. PO � corp. Certificate c�� \1:1 Partner. Business Telephone ® Firm/Co. Name of Licensed Plumber: S -\n Insurance Covera e• Indicate the type of insurance coverage by the cicing thea nate box: Liability insurance policy ® Other of ' PProP type indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under permit Issued for this application will be in comphance�pertiny t th a�prov.si s, Pthe Massac? Setts State Plumbing Code and Chapter 142 of the General Laws. G' Type of Plumbing License D(OFFICE USE ONLY �r icense um Master Journeyman n jf-y6 4Ir t -DOMMONWEALTH ................ ... EAS P A MASTER ,.Lu. -ft'(JES THE ABOVE LICENSE To. -HN. J BLACKER -5:FOREST HILL AVE L NFI'tLD MA 0,1940.-_"17.6,1 i1041 05/01/12 6. 591 & TA L.-- GO ON .- i cj- # 91-8 JMPORTANT' If this license is lost or I destroyed, notify 7th F1 - Of Professional Licensure, Your Board 00r, Licensure, MA 02118. 1000 Waso hington St.". If your. name or address shown Is ation I YOU" board address to insure Proper Mailing Of next Of Correct name r a 'changed, notify Renewal Applic . ,a s *refer to This license IS sub' , ec. t the r vi You" license number as amended. It is affect si ns Of the General La or assigned to a personalprivilege, and m ws nyUstHoff beloaned Person or Posted other person. Keep this license oil Your as required law. tt �� 1. 1 7Z_ Date ... . ........... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . .7P (4�) ... B!��q ko:� ........... has permission for gas installation in the buildings of . 11144,%x. ............... at - OWqYX - AC5F.1 - 4� 4)r;4gj.,q North Andover, Mass. Fee. 4�. Ptq. Lic. No. jP4 I ... ...... fia, el. 41p. J1 a �/) . GASINSPECTOR Check# ZZ -31 7991 MYTI IPPA CO) W LLI MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: 'in&'* 2.r _,MA. Date: 1'24 4 I ti Permit# Building Location:Z , `y I'C'I `� Q�12 Owners Name k\�Ak &Q- &C&j Gr 'JQ_ Type of O upanccyy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential U2 OU New: ❑ Alteration: ❑ Renovation: ❑ Replacement: , Plans Submitted: Yes ❑ NoX, MYTI IPPA CO) W LLI 6i D LU O w w U2 OU H IX w m= Z 1--Z o U) e W � w 0= W 0 H❑ OZ N W w L m co 0 Z to (9 0 F- �> w� a 0 ❑ 0 u� W = LL LU 1,WLu > V i9 J N = W W W W W Z H F— o� a w O Z J U Z a> LL OO W z z w a Lu 0 00 a C9 c9 x=_j O° O a W F- >>> I=- O SUB BSMT. BASEMENT a 15T FLOOR 2 N u FLOOR 3 FLOOR 4TH FLOOR 5 FLOOR 6 FLOOR 7 1HFLOOR 8 FLOOR Check One Only Certificate # Installing Company Name: El Corporation Address:e0 '9�- yn 7 City/Town:3-z9�k4 State: Business Te l:�� "��-��h� El Partnership Fax: Firm/Company _ Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes, No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy El Other type of indemnity ❑ Bond ❑ 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 ❑ Signature of Owner or Owner's Agent Owner ❑ Agent By checking this box[:]; 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 compliance with all Pertinent provision of the Massachusetts State Plumbina Code and Chanter Id2 of tho rZonarni I — B ype of License: p y PlumberZJ'r�-� Title / ❑Gas Fitter Signat a of Licensed Plumber/Gas Fitter 3 Master Cityrrown ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer e The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations ..600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pla— n_;-.&,- Name (Business/Organization/Individual): Address: City/State/Zip _qc� 'M` ©10�0) Phone #: _TS I -� Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ® Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submoit 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: Policy # or Self -ins. Lic. #:_ Ci�j W C l_ Q b7 'j Expiration Date: Job Site Address: 016)\31 zo t It U �\\per �� e City/State/Zip: N•. 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provide(t above is true and correct r-, 0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector Phone .Are you an employer? Check the appropriate box: 1.7, I am a employer with. 1� 4. ❑ I am a general contractor and I employees (full and/or part-time).*' 2. ❑ I am a sole or have hired the sub -contractors listed proprietor partner- on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp, insurance. [No workers' comp. insurance 5. ElWe area corporation and its required.) 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] f employees. [No workers' comp. insurance required.] �'iIIy aYpllCa2t that Ch :.s I3px t=1 must also fill I out f e Section be?ow Ehn.:.;— +1-- ...,. fi Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ® Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submoit 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. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: Policy # or Self -ins. Lic. #:_ Ci�j W C l_ Q b7 'j Expiration Date: Job Site Address: 016)\31 zo t It U �\\per �� e City/State/Zip: N•. 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provide(t above is true and correct r-, 0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 6. Other Contact Person: 4. Electrical Inspector 5. PIumbing Inspector Phone Information and Instructions r� 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 theperformance 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) name(s), address(es) and phone number(s) along with their certificates) 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 retumod to the City or town that the apNlicatmn for the permit or Ecense 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 m 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 of Massachusetfis Department of Industrial Accidents Uffice of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5 -26 -OS ,%N,ww-ma&s...gov/dia 0 rnonwealt�i o1YV%aaaac�au6ettJ Official Use Only c� nsc�Permit No. `% % 2,,Oartment 01 ire ServiceE Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS. [Rev. 1/07] (leave 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 INFORMA TION) Date: November 7, 2007 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1 Village Green Drive OwnerorTenant Village Green Association Telephone No. Owner's Address PMA ( 978) 683-4101 Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Res iden t ial Utility Authorization No.3663245 Existing Service 244_ Amps 120 /940 Volts Overhead ❑ Undgrd [X] No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Meter socketreplacement Completion of the following table may be waived by the Inspector of hVires. 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. o Emergency Lighting Batter 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 No. of Alerting Devices No. of Waste Disposers Heat PumpNumber Total Tons KW of Self -Contained Devices No. of Dishwashers Space/Area Heating KW pDeiection/Alerting al ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Sye ms:r No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Mires. 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 x❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Crowe & Sons Electrical Corp. LIC. NO.: 17168A Licensee: James B. Crowe Signature LIC. NO.: 1 1 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978 453-6696 Address: 576 Middlesex Street, Lowell, 01851 Alt. Tel. No.: 978 251-8573 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001051 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 55.00 Date. /� 7-q� -. "I I TOWN OF NO�RTT ZNDOVER PLUMB PERMIT F,0 PLUMBING This certifies that has permission to perform '4/' -' '07 -S . plumbing in the buildings of at Andover, Mass. '11� ��Vo —rt h .............. Fee4p. . Lic. No..IIZ' PLLIM_�BI(N� INSPECTOR Check # IAI.1,� 8276 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS , ` Date 1® "° � cc, t Building Location Gk j "I I, � f I D % 1 � } �A¢ Permit #a `' \\( Amount �pp 4� Owner V r1( Gl �� CQi-) NM-xrNy,(\ �� New Renovation Replacement ra Plans Submitted Yes No FIXTURES (Print or type) Check one: Certificate Installing Company Namekw-- e®�Ci [I Corp. `w Address �� AX\ -- - El Partner. Business Telephone `1 �� . `�lca_�� Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner [:] Agent 1-1 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 Peniiit Issued for this application will be in compliance with all pertinent provisions of the Massach s to Ph� Code and Chapter 142 of the General Laws. By Signature "censw Plumber Type of Plumbing License Title Z` A> City/Town License Number Master Journeyman ❑ APPROVED toFina usE oNLY The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. T ship and have no employees These sub -contractors have working for in any capacity. workers' comp. insurance. [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other —A.Y F'Y•„'a” Wj quow&h ocrx +r+ USS Uisu r," Ow me section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating currents 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 Iicenses. 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 of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington. Street Boston, MA.. 0.2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax ## 617-72.7-7749 Revised 5 -26 -OS -Arwnw.mass.gov/dia Date /<� - :,� - * ej , ,ORTH V TOWN OF NORTH ANDOVER V00 PE13MIT FOR GAS INSTALLATION This certifies that has permission for gas installation in the buildings of at ......... North Andover, Mass. Fee/1�110- . Lic. No.��11�//- . . 2 'GAS Check # 7 0 u 5 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations 7 ,� .�� t��GS% lV ,,� �� t. Permit # Owner's Name New1:1Renovation 1:1 Renovation Im Amount $ pd cr � Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company Name C1\�r1 �'•`�U�J�"rte Corp. Address 5� �`J`�J� ��\N\ �,y-0— ❑ Partner. y e t os� C�\ N -N K3 usness Telephone El Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [0 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �. Other type of indemnity E] 1:1❑ 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 ❑ 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. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber ❑ Gas Fitter lcense um er Master ❑ Journeyman CG a o 7 x H x N x z z a °o F W w x w x > d zd pOH� > w F WU a F w W > W Z d a d Q O O W a O Wx- x o x w 3 c w x> c a F o SUB-BASEM ENT BASEMENT 1ST. FLOOR 2 N D. F L O O R 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. "FLO O R (Print or type) Check one: Certificate Installing Company Name C1\�r1 �'•`�U�J�"rte Corp. Address 5� �`J`�J� ��\N\ �,y-0— ❑ Partner. y e t os� C�\ N -N K3 usness Telephone El Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [0 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy �. Other type of indemnity E] 1:1❑ 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 ❑ 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. (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber ❑ Gas Fitter lcense um er Master ❑ Journeyman .y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA -02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. I These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no -employees. No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other - ,&uty appilcam coram czecc s rox n m ^' . Faiso iaml out the SC=on below showing their workers' compensation policy infc:mation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractoms that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 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 Vocal 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-contractor(s) 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 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 permittlicense 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 of Massachusetts Department of Industrial Accidents Office of Investiptions 600 Washington. Street Boston, N1A 0:2111 Tel. # 617-727490:0 ext 406 or 1-877-NIASSAFE Fax # 617-72.7-7749 Revised 5 -26 -OS u-A-A%mass.gov/dia D a t e ...... VAORTH TOWN OF N H ANDOVER PERMIT FOR GAS INSTALLATION 7Z This certifies that ........................................... has permission for gas installation -b' in the buildings of —,ad at North Andover, Mass. Fee.k� . �� Lic. No.. .......... Check#, 70U4 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Locations 1� 1 2-i i 23, ZS'j 7, -L�r, -31 %\�W ti,r� a_i lam► Permit # Amount $ Owner's Name GO New ❑ Renovation Replacement Plans Submitted (Print or type) Check one: Certificate Installing Company Name__"` \\\,"��C%t 1`� (�� Corp. Address � ��C �'�� `y '� Partner L X u Name of Licensed Plumber or Gas Fitter ��1� ��Z -E✓ 13 Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityBond 13 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 i nereny certtry mat au or the details and mtormatton 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Sig�e of Licensed Plumber Or Gas Fitter PlumberP3 Gas Fitter License Number HL Master Journeyman w w a O9 v� x O U Gp F x GF r� d F x QQ a O a 0 z d x Z F d 0." W W C4 W �7 U PG m o x 3 a U °a > SUB-BASEM ENT B A S E M ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR .8T H. - FLOOR (Print or type) Check one: Certificate Installing Company Name__"` \\\,"��C%t 1`� (�� Corp. Address � ��C �'�� `y '� Partner L X u Name of Licensed Plumber or Gas Fitter ��1� ��Z -E✓ 13 Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes M No If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnityBond 13 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 i nereny certtry mat au or the details and mtormatton 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Sig�e of Licensed Plumber Or Gas Fitter PlumberP3 Gas Fitter License Number HL Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M4-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizadon/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ 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. ❑ I am 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 3.0 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ BuiIding addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ,&U.y -a-Ye.jcarl maLt crecxs Dox;;; —,&,uzL also W] out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self --ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: ` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). / Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): Permit/License # 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 v 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 Iicensing 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-contractor(s) 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 permitllicense 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111 Tel. # 617-7274,900 ext 406 or 1-877-MAS.SAFE Fax # 617-727-7749 Revised 5-26-05 vr"r"7.mass.,ov/dia I ,OR Pq TOWN OF NORTH ANDOVER -PERMIT FOR PLUMBING This certifies t h a t ........ ............ has permission to perform plumbing in t h e b u i I d i n g s o f at/.? North Andover, Mass. FeeeW.' ..... Lic. No.. . " ............ V?'I 4NS F PLUM6B PECTOR Check # -A�Z-2— -I/ 8274 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location kl 21 �, L j -2.% Z9 �) V'�� - �, , �v � %A h permit # I I Owner V MCAQ Amount Q0, New Renovation Replacement Plans Submitted Yes No FIXTURES (Print or type) Check one: Certificate Installing Company Name 'M,�k.,15A c, 0 Corp. Address C � �� -1\1.1 Partner. ®. Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Ta Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pernrit Issued for this application will be in compliance with all pertinent provisions of the Massach sett State P-lsan ing Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED toFina usE ony Type of Plumbing License 'W312A \ rcense INUMM Master "� Journeyman ❑ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA -02111 www, mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ 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. ❑ I am a sole proprietor or partner- listed on the attached sheet t 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. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 44), and we have no insurance required.] t -employees. No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other - `Ir.y Upp—ilca:.e :nae MOCKS. BOX ;; e r.:n„ . ais: :II out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside 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 isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. Sob Site Address: Expiration Date:. City/State/Zip: of ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 10 Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine. of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 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 Vocal 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 of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 4406 or 1-877-MAS:SAFE Fax # 617-72.7-7749 Revised 5 -26 -OS NA-A'W.mass.gov/dia Date t4oRT" "I" TOWN OF NORTH ANDOVER 0 PERMIT FOR/LUMBING 41 SACMUS This certifies that ................ . -1 ....... has permission to perform . ........... plumbing in the buildings of at North Andover, Mass. Fe 141 Lic. No PVU �VING INSPECTOR Check'# /Vvcg-ov 8275 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 1 � � 11 1. Date Building Location Perm t #110,113- Owner � 3 ' fes-- -T ----, 11 10 �`( , ~4 l? � l \J � Amount D Owner 1-F.c.ly—� w - New ❑ Renovation Replacement ® Plans Submitted Yes No FIXTURES (Print or type) Installing Company Name �fl Address r Check one: Certificate Corp. Partner. ® Firm/Co. Name of Licensed Plumber: Q �1y. G\(-� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0 Other type of indemnity ❑ Bond a Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 0 Agent M 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 Plumbing Code and Chapter 142 of the General Laws. BY Signa a -kensFlumSer Title Type of Plumbing License �� ®�11 City/Town icense um Master ® Journeyman APPROVED tomcE usE oNLY The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations 600 Washington Street BosIO49 ASA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: L ❑ 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 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. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11-❑ Plumbing repairs or additions 12-❑ Roof repairs 13.❑ Other -::.-r appu:.sn< anal ;.becks box #1 must r,Iso fill out the section below showing their workers' compensation policy information. C Homeowners 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 name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employeex Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: 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 apartrnents 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 Iicensing 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-contractor(s) 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 Q policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or r 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 of Massachusetts Department of industrial Accidents Office of Invesfiptions 600 Washington. Street Boston, MA 0:2111. Tel # 617-727-4900 ext 4:06. or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 v��v.ma&s.gov/dia 01 Date. . A? ::?,I. !.<R. . ,ORTN TOWN OF NORTH MOVER PERMIT FOR GAS INSTALLATION This certifies that -. .4� has permission for gas installation -7-X6i in the buildings of at <42,, Fee!6/ 6-01 �?. . Lic. No.Zv- Check #1,-Iq,;- 7006 vr-teA-4-nMover, Mass. �G' A—S IN* S, W� �O'R' , , , , , * , * , , * MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date �Ql �01 0 c( NORTH ANDOVER, MASSACHUSETTS Building Locations `tel Permit # G'C'G Amount $ • D " New ❑ Renovation ❑ Owner's Name,v( � -v \1A Replacement Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company Name n�V ��G� �1•� ❑ Corp. Address�� \ � ❑ Partner. business �Ie ep one 1 -- 1 �b Finn/Co. Name of Licensed Plumber or Gas Fittert1 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes _Ezj No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ 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 ❑ 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 StateKas Code and Chapter 142 of the General Laws. By: Title City/Town (OFFICE USE ONLY) Signatureof Licensed Plumber Or Gas Fitter ® Plumber \\®� 1 ❑ Gas Fitter License Number ❑ Master ❑ Journeyman Wj U F fs C7 OE- dO z z O F w a1 F w a O O O w E- �% w d x x zG F" aO H > H W x v N z H x w tw7 w w x z F d O z o z o r x x O x w 3 A t7 J U a > A a F10 1 SUB -BASEMEN T B A S E M ENT 1ST. FLOOR 2 N D. F L O O R 3RD. FLOOR 4TH. FLOOR 5 T H. F L O O R 6TH. FLOOR 7TH. FLOOR - `- STH. FLOOR (Print or type) Check one: Certificate Installing Company Name n�V ��G� �1•� ❑ Corp. Address�� \ � ❑ Partner. business �Ie ep one 1 -- 1 �b Finn/Co. Name of Licensed Plumber or Gas Fittert1 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes _Ezj No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ 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 ❑ 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 StateKas Code and Chapter 142 of the General Laws. By: Title City/Town (OFFICE USE ONLY) Signatureof Licensed Plumber Or Gas Fitter ® Plumber \\®� 1 ❑ Gas Fitter License Number ❑ Master ❑ Journeyman r r � The Commonwealth of Massachusetts Department of Industrial Accidents Ln Office of Investigations 600 Washington Street Boston, MA -021-11 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bog: 1. ❑ 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. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t . workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10:❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other a:.y-ppil= that cheers box #1 must --so Ell out the section below showing their workers' compensation policyinformation t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. 0 Insurance Company Name: Policy # or Self -ins. Lic.lb #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Signature: Date: Phone #: . Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): Permit/License # 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. r 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington, Street Boston, MA. 0.2111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Fax 4 617-727-7749 Revised 5-26-05 vm-A,.mass.gov/dia Location/ No. 412 e) — a� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 15355 Building Inspeczr f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT y1 I DATE 15SUED; V 310, 1 7_�. SIGNATURE: Building Commissioner/Inspector of SECTION 1 -SITE INFORMATION 1.1 Property Address: rigs Date 1.2 Assessors Map Map Number Number: ao P46 Parcel Number 1.3 Zoning Information: 1.4 Property 'Dimensions: - Zoning District' hVesed.Use ;Lot Area Fronta A 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Required Provide Requimd Provided 1.7 water Supply MGI -C.40. § 54) 1.5.Flood Zone 7nfoimatiort: , Public ❑ Private ❑ zone Omsido Flood zone ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT t L8' sewerage Disposal system: M 1 p Oni�SiteDrgposai:System ❑ 2.1 Owner of Record Name (Print) Address for ServiceJ1* 4 Signature Telephone 2.2 Owner of Record: /%cn9 4 k(Z H Zak" Name Print Address for Service - SECTION 3 - CONSTRUCTION SERVICES 3 sed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Expiration to Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ . o -- Registration Number Expiration Date SECTION 4 - WORKERS COMPENSATION (MG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result' in the denial of the issuance of the building Signed affidavit Attached Yes ...... o.......0 SECTION 5- Description of Proposed Work check all applicable) New Construction 0 Existing Building 0 Repair(s) terations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Speci iNk Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTIONCOSTS Item Estimated Cost (Dollar) to be Completed by applicant. 1. Building / (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical AC �i 5 Fire Protection 6 Total_ 1+2+3+4+5. Check Number SECTION 7a OWNER AUTHORIZXTION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property. Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1C1RC' r1nN 7h OWNER/ATITF—R17SM AGFNT MCI.ARATION I, f as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief rint N Si afore of er/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TT1vIBERS 1 sr 2 No3RD SPAN DEMENSIONS OF SILLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4 ALS IDE 1'� 667 WINDOW COMPANY MELK -PRIIMD iK[Hli�l CP0#004-R-011-006 SOLID VINYL - WELDED - DEL GLZD National Fenestration 13116" IG, DS LO -E, Arson Rating Council Energy Savings will depend on your specific climate, house and lifestyle. For more information, call 1-330-929-1811 or visit NFRC's web site at www.nfrc.org. Solar Heat Gain Visible U -Factor .34 Coefficient . 31ITransrnttance. 51 ..................... . .321 .32 .53 Manufacturer stipulates that these ratings conform to applicable NFP( -- procedures for determining whole product energy performance NFRC ratings are determined for a fixed set of environmental conditions and specific product sizes. ,\ %/c %o-nr,urr,rrrrrrtu/r/ r�,. lG,-urrc/r%sell) v Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 120456 Expiration: 1/2/04 Type: Supplement Card BIL -RAY ALUM. SIDING CORP PAUL MACDONALD 40 ELMONT RD-� ELMONT, NY 11003 Administrator VI • I ;�/fr.r i!wiirrnunrnea�/�. n`, l�nuuc�.uJeilJ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 067195 Birthdate: 08/16/1952 Expires: 08/16/2003 Tr. no: 1191 Restricted: 00 PAUL MACDONALD 25 MASON RDS' DUDLEY, MA 01571 Administrator 1& ,- ALS IDE 1'� 667 WINDOW COMPANY MELK -PRIIMD iK[Hli�l CP0#004-R-011-006 SOLID VINYL - WELDED - DEL GLZD National Fenestration 13116" IG, DS LO -E, Arson Rating Council Energy Savings will depend on your specific climate, house and lifestyle. For more information, call 1-330-929-1811 or visit NFRC's web site at www.nfrc.org. Solar Heat Gain Visible U -Factor .34 Coefficient . 31ITransrnttance. 51 ..................... . .321 .32 .53 Manufacturer stipulates that these ratings conform to applicable NFP( -- procedures for determining whole product energy performance NFRC ratings are determined for a fixed set of environmental conditions and specific product sizes. ,\ %/c %o-nr,urr,rrrrrrtu/r/ r�,. lG,-urrc/r%sell) v Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 120456 Expiration: 1/2/04 Type: Supplement Card BIL -RAY ALUM. SIDING CORP PAUL MACDONALD 40 ELMONT RD-� ELMONT, NY 11003 Administrator VI • I ;�/fr.r i!wiirrnunrnea�/�. n`, l�nuuc�.uJeilJ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 067195 Birthdate: 08/16/1952 Expires: 08/16/2003 Tr. no: 1191 Restricted: 00 PAUL MACDONALD 25 MASON RDS' DUDLEY, MA 01571 Administrator 1& r Z Zfd:•r.,...•_-�.,.�5::�'-tr'�c I --.�•f''+-��-.,--=-^ariw --A� --=is=—w=�� .-v�. 1 Ia , _ ........ : - — '=-_x� o9/2OO 'Ili HIS CE IC I !E ISSUED SA?,441Jr:R0 F It,F ,rzTYA1 PP1 J. c ='Cii� -; IOcJ;1f=cS,1GRIGnISUFON ir!_C=:?rIFICATE -_=��• ' I� GCS I Ii ICl TC DO:` N.tT W.Ello, E No Oj -- __�c� _ _ =Y -i- =C'LICtS3 E" -- -- 'C?1F:I413.1F-CrDNG CC's, z o c ---. i ', =:�.i JC.. _'7 .':G�< �af: .,-'-:=3�1�s ,-.1 L'_�;,c• C=-�r. �;j --s.. . ri I ..... ...J ._ .. - _ _ .. .......... .. ...._--_...��._..-.-.. �, .. .-.. ...._.. __.....- __. .. ,._. ..., _Sic - IJC_ r�, I: _:. _71(Lai - '<' _..'��'._ .-,_.._..-..?A_6 Ory 4tc� kZ- ✓:, rS?CUOYPEO=�': I_4�,•,_, T u, �.'c-�.ir�sr=r�r(�: ,� ��_1-_,:1Y•�-� _- -' -K.'r. d i�„?1 • �lrr , �C=tiJ C.'� 'i17.1R`Or: IC /kICH?!lo U.=.Y Ec L`'P. 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'� �rri ;,T -L I�.ce., I 00,000 r-,�^F_;�_'_ _ I cam.-`--'---`-`,=`'- C_. _1!'-- 0=/ 0^ Imo!' -=La FP_-_CUL,fT 11 500.000 500 , 000 I j I I I i Zfd:•r.,...•_-�.,.�5::�'-tr'�c I --.�•f''+-��-.,--=-^ariw --A� --=is=—w=�� .-v�. 1 Ia , ;�-1-2002 11:15A FROM: TO:15OB4855121 P:2/2 F 10 No 11-9370449 Lk- No, OOlig9 j j � � ' + Job p 'l S I NN NN Lb. ft 120490 MA Lk. No. I:t0000 SALES: FOR ALL Homecentral� N„w Y� a, �°n°° Now York: SERVICEIREPAIRS Tho Sondeo Side of Soare AMMrs tk. No, oYa06aA Nasasu Lk. No. H270410wo 600-942-6111 PLEASE CALL Restart: 886.245-7294 190 Ceder Hill Road Suffolk Lk. No. 21104Hf Yank*?* 1797 S00-SEARS411 Marlboro, MA 01752 wK1er"rr Wcosl3-Ne7 Harllorp Area: 800-SEARS•99 WINDOW CONTRACT New Jersey L1e. No. L011460 Connecticut oat °"°n"""" Providoner Area: tW- lurwblml a Inddht h enFllsy Abri own IWM core. of Rwrww, Mc- o. AnIdM \1r,. No. nneanrl YT LIC. No. _ 0g0g11-732-7751 1111 -SEARS -51 a suit anolaN eoolo 0 4stiumAM. MW. Ar Ilea Rhwle Wnnd Lle. Nu. 19707 SOLD /^ ,� yQ.� �{�v1 4J( 1 L A..P a ZO Irl t L — L d- Z NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF r DATE ADDRESS Q 9 / r p lT �"-' '�3 "�'LVPHONE (Homo) (! 7! �Q �J L SZ Y /4 CITY '`t L STATE 1&7VA;11 yr PHONE (Wook) (j 7e- 7 4 r— ,.fL 1 d JOB SITE ADDRESS (ll d'illoionl) THE COMPANY WILL DEPOSIT ALL MONIES RECEIVED FROM to ea sound ey Oto apreemem. 1 Ownar(s) np►walde 1Fat lira Ills bask 11 APPLIED VINYL WINDOW SYSTEMS '+ QQI1Qr(,) nRSrrlptTr> Work ewe Add,.: Approx• Stan Cale ��'^.4 L Typo of House L l Frame; L9 Masonry Approx. Completion Hate 3 — Zp— d Z SPECfIrICAYIONS Corton rtptx mnkdnln will hr. hrrnEdrml coni uadcraul In 11113c" wpotficallone. YE3/� �Lf Afir PrAD C•ARCrUi.LY ONLY TI IC ITCte,. GNCCKCO YC;: AnE iNu.i nnl-n IN Y4111H f7KnI-H I. LS Rerrique w1ndin—ot Vim qgewrin whnin IlMY nom en lir. 2. fl LCvtL :Operdntp X New Wirelow, af.J faNu LeveL r OpAwnlp a Now ""Mo 9, ri LCVCL N Openings _ a Now Wirrdtnl-. SQ SEMF. NT I.FVFI 0 quildrgp: r Now Windows -- 6. n,4r OIHER A Oponingl a New windows t 7. Lr4 Openings A of Units — s. 6 ❑ ed,dl rum (adtnaMe MoultllnBw Irwlde Stope t of "INS pnmwreil a Ceehty I OI r)Itening9 •• 6. n Insla9 naw Mailer rmrm x of Opening, 10 windnw linea In have rMnhla x1ranlph inculaNM 7)w tow allick less t1. � window unlit to have fusion welded sash r! IT. U New wintlrm twill:: to Wive (union wmltal It'8mo a 13. Now window units 10 have Clime -Teen loselgaMMAWq of Low•E cooled, pit rlkd inndnlnd nhc K"IIwdl. le 0 e, wirrtnw trolls to have Cam Look(c) or Latoh Lock(s) 111. ❑ flew wlrrdpw WON iv Ime Obxvred aluoot d sere _. Fera 16. .New wuxlow units M fulm Irdl (1 f?) rJeY M (hie !onion an ossa wlndow) 17 Inwlon PVC eoNed al mb urn to window frames C40W; ►? "F a to (tleelirn)a T I auer e. Cand soul win*, . wllh A Imtld .y::innl I R. I Hanave and alspoes of axis or storm Windows 20, C� 0 of wmdovn to be `�C� ?1 U Wlrekrrrr: to 111rvn fill olyal LliimorW ❑ FtiA D 112 Adddivtad inly 22. G rohA N 0 lkaak Hrrnp: Tacit N M I rappers Toot A of Caavmenh ,.....r. Tekd p Ill AwrrMp Total d at Iwo LAo Sliders Toler M of Three Lire fSIIders _ Sid (ir Frlrud 0101 a of 4sad I llcvp ,rrm. Tot if 0 of Beseiment Minis 7A r I IS•ra Tal Older Windows (tn Addition to Above) _. ,..- ,.. .. _.. pito Q'/❑ t rinn up on Iron rnkilml rrrluk will Ion itinuAlMi from pr8peny on Completion of work. ' 25. F_1��1 encu wUl worbnans compirmalion and rrablily it igrwk irwd 20 (ems LJ M(Mdy MnliM M rirrrrrrerr upon c %*9an Intl lull payerem N received �et te+reu^a rNw rw^kNwe 27, 11 PVIRW is—dolt Aon nrtm-Ad Md7ra) I' firrynMn In inatnllrr ar day M klaraMlian. 79 I 1 An MaXintc have been applied. Cash Sale Total r Le66 deposit 3$% $— Cash B3L9nrA S) 7� Other Payment (ill any) $ _ I I CASH ( FINANCED $ 37 r *—+a- docs not Include interestpp�� Balance on Substantbl ComplAtion $1:r6, II finanrod. holiteme peyatie lit A,-WIV , nenrtlihr kdtlaamools of approxi neleN 8J 41 �- par month, payable by "Owner to wrivactor, but a IManend by Owner Ihm Owner will pay cetd amour, to the 111014 Q 1ASMIAkn plus sUCll Interest end onac t service delrpr. 01 -;ukf kxefrrr) ImUkxlon payable "ctiy,to the lending insdluaon foartino such mordes to "Ownee and will oxowl0 a FWail InolnerrWil (rh101011 will any documents required by such leyastg InvtlaAbn In connection VANAW 29 ar ❑ Mllndnm drnmmirm d1T- rrta.4x t[sy 4 ; ✓'r`J i7` a Ulk-a-Al-TI - - an IW"'/11 Wok fieri to be U04 a� 1 -(;UNIIIACIUII IJ NUI 4,PQN1q0 F F -OR ANY rxlrTINC. nircuRITY CYSTEMS. PLEASE REMOVE ALL SMAOFS, VbH11CALS. UUMIS, CU141AINS. UHAPPS OR WINnOW MOUNT1-ti Ain CONCITION@nS. PRIOR TO THF INSTAI I AT1f1N MYIHIN NFW WIN - Ly RVti iNSIAI I FAS ARF NOT RE:,PC)N51DL[ roti Tt I[ nEMOVAL OR INSTALLATION (IF 1NPRP IY"..% of, I I i-Ms.— Nolloe• If Hnaeced, any holder of this Consumer Credit CoelraclIss soh, CONDENSATION INSIDE THE HOUSE DOES NOI INDICAIE A WAHRAN- against all u1 goodsnordsenlees Which o ap�anl hotels Meto TY PRODLEM ob4lnCO3 alit with the pmcands heraol. Recovery by the debtor shell nol gntaed emounte peld SALESMAN HAS NO AU IHORII V TO CHAHIIF ANY ITFMS OR MAKE ANY by debtor hereunder AND THAT NONE HAVE BEEN MADE "OWNER" REPRESENTS TO "OWNER REPRESENTS TO HAVE READ AND RECEIVED A OUPLI• RELIED UPON BY "DWNFR" YOU ARF FNTITL FD To A COMPLETELY CATE ORIGINAL OF THIS AGRFFIAFNT AND 10 BE THE AUTHO- rILLED IN DUPLICATE ORIGINAL OF THIS ADREEMENT. RIZED AGENT OF At 1. "OWNERS" OF THIS PROPERTY UPON »YOUTHE BUYER MAY CANCEL THIS TRANSACTION AT ANY WHICH THF WORK OR TIIE MATERIALS ARE TO BE SUPPLIED. TIME rPf1108 TO kRONIO T OF THE THIRD BUSINESS DAY NDDCE ID r11L110ME OWNER(S), GUARANTOR($), LESSEE($), CO-SIONER(B). AFTER THE DATE OF THIS TRANSACTION. SEE ATTACHILD NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF Comtraoler, at the expense of owner, shalt piocala all pnrmilo required THIS RIGHT, ON ALL ORDERLISIOMERS S CANCELLED CANCELLED AFTER THE RECISION 1. Tutee rlt BE NSIBLE FORA 45'Y. free secure their own permits will be excluded tram the 111111110101111111111% AOMINtiTRATIY AND RESTOCKIING FEE. gUa►aMy of MSI Chapter 142A. 2. Anyperson who shall have ee•Algnad, riarantsed or signed any credit application or nolo rotating fro this agreement hereby Acoll THE COMPANY WILL DEPOSIT ALL MONIES RECEIVED FROM to ea sound ey Oto apreemem. 1 Ownar(s) np►walde 1Fat lira Ills bask i Ilii ESCROW ACCDIINT AT CHASE MANIIATIAN SANK A10b 1 cvrrlaMs sit of Ude agpreement send hie been I11 a IRM hen011-00111-:3. by llwnar. 212089 WITHIN FIVE BUSIN03, D YS OF ITS RECEIPT. ppsR nod end scceplad a. ALL INSTAtIATION LABOR GUARANT[[D I (ONEI TEAR. Dale Z ' L�� C Z _ De net slpn this agreement before you read It or 11 It contain any blank space or 11 it docs not cooloin everything allied upon. Prlrd DATE 2,7 Sel Marys Name ..._ +Ignanno 1st i / �(i(I,flpnrre AiXI MWM Saloaman'F Lkenso No ... .. CII�relllun SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS' Revlsrsd 4101 O z PO s? � ro o o w w rn rn W �' U a v g z° A a .a z d w oIrl9 ,', x a a ��, o W W u .� o o a w z° D 41 o u. rn w U i:. (n U) Z H ca W H W U CIO F— _ .�. 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