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HomeMy WebLinkAboutMiscellaneous - 10 OLD FARM ROAD 4/30/2018a - 10 ii: n,) WN OF NORTH ANDOVER PERMIT FOR PLUMBING ..................................................................... plumbing in the buildings of ... js.d.,,J .............................. zA �-- 1 at ...... / U / �� /-1 Of . ...... ................................................................................... ....... North Andover, Mass. Y, do ......... ... ... Feel.;� . . ...... Lic. No./5�$.z ... 2-- 1�14 . . ............................................................ PLUMBING INSPECTOR Check # 601 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ r MA DATE C PERMIT# 16 / D,- JOBSITE ADDRESS (� O�ci . Y Cz OWNER'S NAME OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL EP NEW: RENOVATION: © REPLACEMENT: FIXTURES Z FLOOR- BSM 1 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM IL._,_ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY I _ ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL I WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES WATER PIPING _ t OTHER 1 F 2 1 3 1 4 1 5 1 6 1 7 RESIDENTIAL S PLANS SUBMITTED: YESE11 NQU 8 1 9 1 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ( NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 01 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in iance wit Pertinent p ��rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME r0 aY' IILICENSE # S 3 Z I SIGNATURE IVIP JPQ CORPORATION n#©PARTNERSHIPQ#LLCI COMPANY NAME v- ADDRESS _ v CITY y_er�_ STATE lig- ZIP �Q a 1 _s �___jj TEL FAX CELL EMAIL Q_ Q (J_U.YI✓L j� �� C �: IV - m N ❑ LU CL ui LU LL t The Commonwealth of Massachusetts - Department of IndustriqlAccidints 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 Le0bly Name Addre: City/State/Zip: 0--c V i lie MA Phone #:_647 V3 2DI Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. [�LI am a sole proprietor or partner- listed on the attached sheet.1 7• ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. 9 y p ty E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. [RPIumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis 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. Lie. #: Expiration Date: Job Site Address: 1 p toV C -ow vv Qel .City/State/Zip: b. AY�L UeV- r0k Q l $t s Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c�6 under f1ie pains and penalties of perjury that the information provided above is true and correct. Phone #: '6(7 q(3 a ( Q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License as./ i 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 employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have 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. AIso 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 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 Mossachusetts Department ofladustrial Accidents Office ofInvestigatlons. 600 Washington Street Boston, MA, 02111 Tel. # 617-727-4900 at 406 or 1-87TMASIRAFB Revised 5-26-05 Fax # 617-727-7749 �wV�.m,ass,g4�fdla 1 COMMONWEALTH OF MASSACHUSETTS ` i PLUr4BERS AND GASFITTERS LICEN" ED AS A MASTER PLUMBER- ISSUES THE ABOVE LICENSE TO: r AI i-.JANDR,9 fD AGU I AR 44 CARLETO•N ST F REVERE MA -02151-446 e_ II F 1-,329 05/01/14 153688- L ,. -9 Y4 Date..//.-. 20- . eY4 ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ............... . .............................. has permission to perform .... . ..................................................................... wiring in the building of ................................................................. at .... North Andover, Mass. ........................................ ......... 4 ....... ........ Fee .............. Lic. Nm�, ECTRICAL INSPEc-roje Check # //,3c,-2- ,a—,b 7073 I Official Use Only �_... Commonwealth of Massachusetts - _ - Permit No. -_C __:---.--- - Department of Fire Services EVENTION REGULATIONS � Occupancy and Fee Checke�Q BOARD OF FIRE PR ;[Rev. ll/99] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAMR QtWORK All work to be performed in accordance with the Massachusetts Electrical ( f� / ("PLEASE PRINT IN L%!K OR TYPE ALL FO PION Date: �-d- --,—() _ -- Town of.. :t�j����+�------ ... __-- To the Inspector of Wires: By this application the undersigned gives noticef ohis or her inter ion to erform the electrical work described below. .Location (Street de Number) _ _ Owner or Tenant � JNU Owner's Address_ Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps Volts Overhead New Service Amps / Volts -- Overhead �..� Number of Feeders and Amp;acity _ Telephone No. Yesi No (Check Appropriate Box) Utility Authorization No. Undgrd Undgrd No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: �,%/ C /t • ulE2tZ(ta- c --'t 4 -- _ Completion of the following table may be halved by the Inspector of Wires. No. of Recessed Fixtures �No. of Ceil.-Susp. (Paddle) Fans - i ( ansf tjp.�rs_-m KVR-.-.-.- No. of Lighting Outlets INo. of Hot Tubs Generators K V.A -�- --- iSwimming Fool Atbave �l In- N of Emergency Lighting No. of Lighting Fixtures---!nd_�_� I3a[tery t;nits Na of Oil Burners FIRE ALARMS No. of Zone. # OF No. of'Receptacle Outlets ___ _ CIRCUITS: -------- ----------------- --1No of Detection and No. of Switches No. of Gas Burners - -- _ - -- ltnioatina Devices-----------.....--------.-----_- Total No^ ofAlerting No. of Ranges - -- - -- - - No. of Air Cond. Tons _ g _ ^ _-' __,No. of Self Contained No. of Waste Disposers Heat Pump Num er Totts _-� ._K� !Det _ - p 'Totals _� _-� --�_--ect�on/rllertin�De�ices �_-...------._-_- ---1 Municipal,, ther No. of Dishwashers Space/Area Heating KW Local Connection Securi y�stems Heating Appliances K�+' iNo of Dryers �-g pp _ _ No_ of_ evices or Equivalent __-___ No. of Water --- - ,._ - No. of -- - No. of -- - Data Wiring: .Heaters _-_-. E•th -------- Si res __ Ballasts ----------.--- No._of De_v_ices or Equivalent --- - —v Telecommunications Wiring. No, Hydromassage Bathtubs INo_of Motors---E'otai HP - -�No. of Devices or Cguivalent__-- _ .._. _ _ ..- ;Other: Attach additional detail (desired. r as i-eyuired by the Inspector o, Wires. �w 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" ;clverage or its substantial equivalent. Tboc Cy undersigned certifies that such coverage is in force, and has exhibited proof of same to the ermit issuing office CHECK ONE: INSURANCE42fOND ❑ O'f HER r(Specify:' Uabk� �� !��_.._.. i Ex tralloa I)utc, Estimated Value of Electrics Work: _ _— (Whet] required by municipal policy.) Work to Start: i l� — Inspections to be requested in accordance with MEC Rule 10. and upon completion. r' r hat the in ormation on this a ulication is true and complete. I Certift. under ;)ae pains and penalties ofxe A }, t - ,f 1. FIRM NAME: Licensee: tz�L/UVA& (If appiicable. ent r xernp " in the !icer Address:-- — < w OWNER'S INSURANCE AIVER- required bylaw. Iia >ny signature below re I am aware the the Licensee does . I hereby waive this requirement. Owner/Agent Telephone No. Signature --. ...... ------------------ - ._-- r LIC. NO.: - - LIC. NO.:�%/. Bus. Tel No.: Alt. Tel. No74--y-TW(j not have the liability insurance coverage normalK r am tie (check on:-) `�I owner [ ! Owner's agent. PERMIT FEE: S -� �'l .✓ A/w/W Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................. ....................... has permission to perform ......................... ............................. ............. wiring in the building of ... ........................ ....................... .............. I ................... /C--- ..... . North Andover, Mass. ,i Fee ... Lic. No. ��� ............ "J".4 "-'� llz�. ......... ............................ ........ -roR ELEcTRICAL INsPEc ,-.;,Check 41 5 /'.� b z i 4 Commonwealth of Ma Department of Fire BOARD OF FIRE PREVENTIOI APPLICATION FOF All work to be performed in (PLEASE PRINT IN INK OR EYRE ALL City or Town of: By this application the undersi d gives not Location (Street &umber) /�> Owner or Owner's Address SsaC usettS Official Use Only $ ICeS Permit No. Occupancy and Fee Checked j V EGULATIONS [Rev. 11/99] leave blank IT TO PERFORM ELECTRICAL WORK with the Massachusetts Electrical Co��C), 527 Q'MR 12.09 MAT ON Date: - To the Inspector of Wires: or bbgr intention toP9rform tt}e electrical work described below. Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ? Telephone No.y Yes.. ❑ ., No Utility Overhead ❑ Overhead ❑ (Check Appropriate Box) ition No. Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Installation of Security system No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Above Ej In- M Swimming Pool rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers ..-. Heat Pump Totals: Number Tons KW No. of $elf -Contained Detection/Alerting Devices No. of Dishwashers - . Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers HeatingAppliances KW pp Security Systems: No. of Devices or Equivalent No. of Water KW Heaters No. of No. o 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 aaamonai detail g desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) QI (Expiration Date) Estimated Value of Electrica Wor : O (When required by municipal policy.) Work to Start: WInspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the ains and enalties ofperjury, that the information on this application is true and complete. FIRM NAME:Secur-ity LIC. NO.: 153�� Licensee: John S. Bassett Signature LIC. NO.: 1533C (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 603 594 5928 Address: Alt. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Lid, see 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: $5� Location /o ;X"," �� No. 1272 Date TOWN OF NORTH ANDOVER -A Aw- Certificate of Occupancy $ Building/Frame Permit Fee $ Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 175U 4 ` TOWN OF NORTH ANDOVER ' BUILDING DEPARTMENT XPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1.2 Assessors Map.and Parcel Number WELDING PERMTr NUMBER: DATE ISSUED: 0? r _6 ;IGNATURE: AJ4,0�' ,,U7 Buildina Commissioner/Insvector of Buildings Date TrTinN 1-RVIT. INTnRMATInN 1.1 Property Address: 1.2 Assessors Map.and Parcel Number X Map Number .Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: roning District Proposed Use Lot Area Fronto " 8 .6 BUILDING SETBACKS ft Front Yard Side Yard Rem Yard 1Uquired Provide Rcquired Provided Reqdrcd Provided J Water Seapply M.GI..C.40. 54) 1.5. Flood Zone Info�ition- Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑, ublic 11 Private ❑ >ECTION2-PROPERTY AGENT i � t t• '-';iii!•"A '.1 Owner of Record lame nnt)� Address for Service: ;j g re Telephone ;,2 Owner of Record: Name ``Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES Not Applicable ❑ 1.1 Licensed Construction Supervisor. n men .icensed Constriction Supervisor: 1.2 Registered mc, �ompany Nan 0.ddress C511? ��S-b llaYUl �License Number � Expire on Date Not Applicable 0 f 3 (,q Registration Number <� /(4 a -- Expiratio Date V M - z O W'I svo `I ufuvN OZ uHiDdNNOD JNWm l£i.SI QNd'I GHTH3 NO CII'IOS NO 0MCTS Ilg SI AdNYMD d0 TVM9.LVI X o aLOOci .IO 37I96 SSHNNOIKL N0UVUNfI0d .IO JADE -I S?Idcoo 30 SNOISNHMU S.LSOd d0 SNOISNHMCI STUS 30 SNOISN-W(f NddS £UNZ I suagml 2I00'Id IO dZIS UVIIS XO LNJNHSVEI dZmS SmO.LS 30 ,ON aluQ lua d/launsp)o amlu Ar F au ltna Jatlaq puu Apalmoul Atulo isaq atp of `alemooe pus anal a1u uotimilddu 2alodalo3;np uo uot;ewojut pus sluatualMs agl imp amImp Aga1aH • rClladoid loaCgns 30 lua2d Pazuotl2n`d/taunt0 s�l `I NOLLE-l:)ga INaOV ajMojUfld , aNMO qL t4oljdas, also aaunAO3o a tS •uotleoiIddu i*uuad gu!pllnq s dq pazuotpns 3I1om of antlRIasialtut1 Ie ut ; e' AW ' uo Jos of azuotpnf AgalaH dlladoA laaCgns jo lua'Sd pazuotpnd/iaump su ` I .LI ATRU 9NIQ'I 9 HOA S3I'IJJV H0J,3'V-dJ.N0 HO NaOV 992NAW NaHM ([ILa'ld gO:)19 OZ NOI.L1/ZIHOHIAV H3NtAO RL NOI.LZ)'JS laqumN 313ogD o S+b+£+Z+I Fol 9 (q) --*j ;tuuad Buippng --- uoyoalold ani .9 DdAH) immuqmNt b �fulqumid £ uoilonalsuoD 30 lsoD iulol palsuulsg (q) --�`Ip3!40a13 Z 1511 nInJ�I 903 lituaad �uipling (s) Su1pling I A wo a'SIIwI moo lusotl p iT , q palal u1oD aq of (mIIo(I)1soD r*lpunlsg u131I SJSOJ NOLLOfIN.LSNOa (laiLv I.LSa - 9 NOIims :3I1oM pasodoldjo uollduosaG j;)ug AdIoodS ❑ laglp ❑ uollgOumG D •2pig Alossaaod D uogippd D (s)suoilmlty ❑ (s*e&x ❑ Sulplmg gullstXg ❑ uollonllsuoD MaN alq-u a uv-4 $aoM Fi oad;o uoy uasaQ S NOLLOaS 0....... OR ....... saA PagauuV 3!AVPDP Pau !S ;1 uTpnq aq; jo aouunsst alp jo Iu!uap aq; u! llnsw Utm I!nupEge s►q; op mud o; ainguq •uoquotlddu s q;u� paurtugns pue pa;atdacoa aq yrnui;inupgp oouiunstq uo!lnuodwoo s1a�Ilo A (9)3SZ § ZSI 3 'I'O'AU NOLLYSNUM3 SHI RIOM - ti NOI.LJHS 1 �M Ems* I x r v a O U A 1 Y 0 c �S Ems* I x x v a O U A 1 Y 0 c �S W �I F O a m f Q° a vN V : 3 m w C_ o c A CO o w cR `Ea w w :� U G w o w x CL aG N w rs: w" rA cn cn D J O F=4 c z o CD m c 1 Y 0 c �S W �I F O u Q f Q° C O F=4 c z E LIG Z CA H i 73CDm Im c m 0 CD c c s 0 Z O U O O 2 E Z a O H � C cm I C C H p C y � � co Z 0 cc0 d 6L cmcc ca cc 0v C Z CL v vs cc� C C C GO 0 LU 0 U) LLI U) 19 LU L1 LU U) o CD m c c �S �� o � mm O o C vN V : 3 m ccm C_ o c CO o m `Ea = C h O o m SD CL N CLC -3 ` O � c oC v $ E LIG Z CA H i 73CDm Im c m 0 CD c c s 0 Z O U O O 2 E Z a O H � C cm I C C H p C y � � co Z 0 cc0 d 6L cmcc ca cc 0v C Z CL v vs cc� C C C GO 0 LU 0 U) LLI U) 19 LU L1 LU U) CD aM �� mm o 0 CD : 3 m C_ C � CO = C h O SD CLC -3 ` Goom fo oC v'—oio 2 T iam •� w o W C � ig;Z WC& O IV)� N ci C3 COD CL a fiem== S �= w a=m E LIG Z CA H i 73CDm Im c m 0 CD c c s 0 Z O U O O 2 E Z a O H � C cm I C C H p C y � � co Z 0 cc0 d 6L cmcc ca cc 0v C Z CL v vs cc� C C C GO 0 LU 0 U) LLI U) 19 LU L1 LU U) xWorkers, The Commonwealth of Massachusetts Department of Industrial Accidents AFeRN is 600 Washington Street Boston, Mass. 42111. nnensation Insurance Affidavit: BuildingWPlnmbing/Elect� ' r#Xv—A a f"Op - 0 ■ • 11 homeowner •:! 1 II 11 'all workmyself Project Type:.. 191 1 1 1 «1 /•11 X11• 1 ■ .I11 1 11[1.1 • and 1 11 one 11 .II 1 1. Building Addition 11 r ' am. 1 MPIOYW providing •I 1 1/ 1 iwl 1 1'i 1 /l qi/piqees working 111 I / 1 of 1 11 1 I 1 � IJ. '►ice S o •. • -cy �propnc�tor. 0 ■ 11 11 1 / 1 / I I II 1 I , and 1. 1 :1 1. 1'I 1.«•�Iisted�L�O have thefollowing workers' polices: eompany name, . 1 insunnee co. I MI WE MAN/ /, Company usafe: phone 1 .11 f: I 41 I 1 Failure to Secure coverage as required under Section 25A of MGL 152 can lead to the imposition of crh Wnal penshks of a fine up to $3,500.00 and/or one years' tmprbonment as well as eivll penalties In the form of a STOP WORK ORDER and a fine of $100.00 a day agatnst.me I understand that a copy, of this statement may he forwarded to the Oiilee of Investigations of the DIA for coverage verifieation. I do hereby certify under thepains and penahies ofpedwy that the information provided above is a ze. and correct Date Print name Phane # l WAS efricial we only do not write in this area to be completed by etty or town offichd city or town: pernstokeme 0 OBadding Department OLleeming Board ❑ cheek if immediate response is regtdred []Selectmen's Office Health Department . contact person: phone #; []Other O-bw Sept ZO). r Information and Instructions . Massachusetts General Laws chapter 152 section 25 requires all.employers to provide ;workers' compensation for their employees. AS quoted from the "law", an employee is definedas 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, C'D poration 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 tin-ce apartments and who resides therein, or the occupant of the dwelling house of .another who employspers ons 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 section 25 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, neither the cornrnonwealth 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. ---------- ---------------- 44 --:1 Y•1 10'• /l 1I C 1 IFI •• top / / ! . ♦11 : 1 . • 1 • / :. • • 14IN411 • 1 I• 1 • '1 1 1. 1 / 11 w 1 1 / iTS)I(41111 CC1' i .! 1 1 • 11 i 1 Y . 1 . `1 1. /. 1 • 1 / 1 1 �• 1 1 • 1 • 1 1 :1 • / • • ` 1 1ail . 1 v: 14 DO 1 • 11 - 1 - I • 1 1 I - I1 ' '. :� • II 1 �:/ 1 1 • /1 / 1+1111. 1• / • 1 - 1 ! .�/•/ � •/I1' 1- � • • 1 1 :1 • • 1 Y. 1 • • 1 �1 1 1 • 1 / • / �''• 1 � - 1 t/1 ail 1 1 111 / :. 1 • 1 1 ' y, - , - 1 `, .. • 'J 1 1 / 11 : / J / 1 � :1 . 1 / 11 1 . 1 • • : 1 / . 11 • • • 1 • 1/ `e • . • • • it • u 1 - .'1 u ' -• • 1 .� 1 • , • • / 1 : • «• / .: • :r. /u1 _ 1 - • • 1 .- 1 • 1 ! 1:1 111 1 1 1.f 1 ! 1 1- :• 81 1 1111.+ 1 111. A 11. • 1 1:1 1 • `• • 1 1. 1. 1 1 1 • 1 1 •• it 1 1 • • ••/- . 1• I 1/ 1• 1 • 1 1 1 .� 1. 1 PON �/,%i/� 11 11 it i t 1 • �� 1 1' 1 1 iil 1 1 1 1 • y 1 1 111 1 1' 11 1 :1 11 1 1 . 1 1111 1 •1'11 11 1, C ti M.C. CONTRACTING, INC. 62 Constantine Drive TYNGSBORO, MASSACHUSETTS 01879 ar�opo��a 1 PROPOSAL NUMBER: 281 (978) 649-2073 Fax (978) 649-1471 PHONE DATE TO: David Yue 978/448-5692 6/11/04 10 Old Farm Rd JOB NAME / LOCATION Shingle Roof Replacement N. Andover MASS JOB NUMBER JOB PHONE We hereby submit specifications and estimates for: > 1. Supply and install poly tarps to the side wall and grounds of house for protection from falling roof debris. 2. Remove and dispose of existing asphalt shingle roof. 3. Supply and install new white aluminum drip edge to all eaves and rakes. 4. Install 6 feet Ice and water Shield on all eaves and valleys. 5. Supply and install 151b felt paper to the entire roof deck. 6. Supply and install 30 year architectural asphalt roof shingles. 7. Supply and install new exhaust pipe boot vent flashings. 8. Cut roof deck at ridge 1/2" on each side of ridge pole. 9. Supply and install new cobra ridge vent. 10. Supply and install ridge cap over the entire roll vent. We Propose hereby to furnish material and labor — complete in accordance with the above specifications, for the sum of: Five Thousand Eight Hundred and 00/100 Dollars dollars ($ 5,800.00 Payment to be made as follows: Payment upon completion of work. M.C. Contracting warrantees workmanship for a period of 5 years. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado, and other necessary insurance. Our workers are fully covered by Worker's Compensation insurance. Acceptance of Proposal—The above prices, specifications and con- ditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Authorized Signature Note: This proposal may be withdrawn by us if of acce ted within days. Signature Signature PRODUCT 13128M USE WITH 771 ENVELOPE NEBS To Reorder: 1-800-225-6380 or www.nebs.com PRINTED IN U.S.A. AA () i N 6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 085086 Birthdate: 0712311979 Expires: 0712312007 Tr. no: 85086 Restricted: 00 STEPHEN H OBRIEN 56 FITCHBURG RD #531 TOWNSEND, MA 01469 Administrator Board of Building Regulati ns and Standards 7HOME IMPROVEMENT CONTRACTOR Registration: 133895 Expiration: 8/2212005 Type: Public Corporation MC CONTRACTING INC. LEONARD MARTELL JR.. 62 CONSTANTINE DR. TYNGSBORO, MA 01879 Administrator License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, 10a. 02108 Not valid without signatu r k Location /0 No. - k -;� Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL O.Building Inspector Y3117/Z14:32 0o PAID 9 3'r"15 Div. Public Works PER3'gT NO. " APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. /'/ PAGE 1 MAP K40. LOT NO. 2 REC RD OF OWNERSHIP IDATE BOOK :PAGE - ZONE SUB DIV. LOT NO. I LOCATIONa p PURPOSE O BUILDING i1 Y/A OWNER'S NAME OWNER'S ADDRESS NO. OF STORIES SIZE BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME / iii / ( / SPAN -- DISTANCE TO NEAREST B/UICDIN�GG DIMENSIONS OF SILLS DISTANCE FROM STREET 6D POSTS DISTANCE FROM LOT LINES - SIDES -,/ ,C/ REAR '�lr " GIRDERS AREA OF LOT / FRONTAGE / IS BUILDING NEW (.�+li-"`t /I/ �fJ HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X IS BUILDING ADDITION /l /j MATERIAL OF CHIMNEY IS BUILDING ALTERATION 4./0 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO QUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 CELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BEGV D AND APPROVED BY BUILDING INSPECTOR i DATE FILED ,� / I D SIGNATURE t;"WNWR OR F E E PERMIT GRANTED L 19 AGENT w455 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSP[CTOR OWNER TEL. # CONTR. TEL. k CONTR. LIC. # H.I.C. k 1 � � BUILDING RECORD THIS SECTION MUST SHOW E7FACi`DIM44 4`0- ico"f V�STAG�C�E FROM LOT LINES AND EXACT DIMENSIONS O ILDIN' PORCHES. GA - RAGES. ETC. SUPERIMPOSED.i ll.l\S R€R `�` , PLf�7`,lr J\ _ t i v \ t \ i, \ �� J �\ \J � 1 OCCUPANCY SINGLE FAMa=. s�o s. MULTI. FAMILY OFFICES _ APARTMENTS CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE PINE HARDW D CONCRETE BL K. BRICK OR STONE PIERS PIASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL +/1 1/2 l/, NO B M T FIN. B M AREA FIN. ATTIC AREA FIRE PLACES HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 _ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING _ CONCRETE EARTH HARD"./'D COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. d FLOOR I_ CONC. OR CINDER BLK. _ WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR11 I� POOR ADEQUATE NONE 10 PLUMBING S ROOF GABLE I HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. 42 FIX.) _ FLAT SHED ATR CLOSt-, ASPHALT SHINGLES LA T -Y- WOOD SHINGES K SLATE NOP BI TAR & GRAVEL STALL MOWER ROLL ROOFING MODE FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COILS.OR WOOD RAFTERS _ VAPOR AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. 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