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Miscellaneous - 103 PUTNAM ROAD 4/30/2018
Datb.......1 .........1.�...............:.......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION U jlr Thiscertifies that.................................................................................................................. has permission for gas installation �....?.- ... `� ...�.Q in the buildings of ..............!'�"' ��"' at .... ki'?........ T a .. ,North Andover, Mass. .... .......................... .......................... Fee ky)..... Lic. No..S-v-'..1'� ..."`.................................................................. � GAS INSPECTOR Check# ����� 21 l 0 ,.O MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover I MA DATE 3/2412014 PERMIT # "I Z11 —1 U' JOBSITE ADDRESSI 103 Putnam St OWNER'S NAME ozo GOWNER ADDRESS Same TE � IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONALE] RESIDENTIAL❑ PRINT CLEARLY NEWT -1 RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES® NOD APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER j BOOSTER CONVERSION BURNER I COOK STOVE j DIRECT VENT HEATER DRYER FIREPLACE _ FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE 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: OWNER ❑ AGENT ❑ 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 c mpliance with all Pertinent pr(� ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE # 8736 SIGNATURE MP ElMGF El JP ❑ JGF ® LPGI ® CORPORATIOND# 3285C PART SHIP❑# LLC ❑# COMPANY NAME:1 RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE LE]ZIP1 01501 ]TEL (508) 832-3295 FAXI 508-926-4347 ]CELL 508-832-4614 EMAIL JMarino@RHWhite.com W F� O z z 0 H U W a d z w ❑ Z° z O N❑ w CD O ~ w LU a- O U w z Nw .. Q a O w w w Q W N a d � a c U x J F a a a � Lii x w H LL w E� O z z 0 u w a z c� 0 a y -------- ':LEv • tc{; i7i: P,;j' ,i '+I.: (s,t 9 d1' Y1M .:,, ., did': •f,c ! ..y^��f. of �' - "d ,, i;,. :.I'. !yg� ' ;!;,, � • ,:`: i"Ir ,: �:' ds—?".a U. i Nt dF- u Li, LU Z . -'m . .Z' -.cA• uaw W.' 'IT iiia.. .F �> a p CD LY • .�,., ; i�„en',., =;;A',; ,:.fir ,:, �!-t,:;,, •.r`4�, li.��!,�i; ��1 C.''' :"��.., r;;i ,`'int. ����r::• r''�;:; � iUJ :5\•i'tilts,.T v.- (ii.,.t; Ki`11F' `t 'li:i.: .:... ��:I.'t.:,.'i:.:..,it�'..�•.l:'i:'�.�..j:')f.:,:;,S ,it,: �.'rilte.i: -------- .:,, ., did': •f,c ! ..y^��f. of �' - "d ,, i;,. :.I'. !yg� ' ;!;,, � • ,:`: i"Ir ,: �:' ds—?".a Mitt' '£. ' e • �y,,;�hr '•.;y, ; :t:,' �'ilF :i; i:. is 15� :4:'i i:!rl: (�, LU uaw W.' 'IT O �> a p �Q-mo,z � iUJ LUIXU) Lo110 t 'f: l :I:';. '�f} ;.•1..%:r .:�Iftl:: 1�_j�s'; ,'iill Y { L'tre ' . .s lni'': �,✓ ...t%.;: 1;�,;• lt:."'.!��'`.,::. ,'i%rel i,1 ml 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 ACCORD® DATE (MMlDD/YYYY) �—; CERTIFICATE OF LIABILITY INSURANCE;,,,, 1 oQ 1 08/29/2013 1'HIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Polic0es)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsoment(s). Willim 09 Massachusetts, Inc. c/o 26 CQ-Atury Blvd. P. 0. Box 305191 Nashville, TN 37230-5191 R. H. White Construction Company, Inc. 41 Central Street P. 0. Box 257 Auburn, MA 01501. _y'A9-7378 1 inir nun%. RRR_491- .,Hernia ,�rrv,auirv�a WvtKA'�'NAIC rt INSURERA!The Chartor Oak Fire InauranC9 Company 25615-001 INSURERS:TraVQ10rS Property Casualty Con>jpany or Am 25674-003 INSURER C: Nati=Al Union Fir9 Insurance Company of 19445-001 INSURERD; Travelers Indamnity Company 2506-001 ..�,.,,, ,��,M evun�ocrc: aV/.tl-/DCV REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 16SUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LMLNSR TYpEOpIN$VRANCE b0SUB �FQLICYT POLICY EXPPOLICYNUMBERLIMITS A GENERALLIANLITY VTC2000 977X9948-13 9/1/2014 EACFIOCOURRENCE T 2_lltlfl.(l0f DED I X ]RETENTIONS 10.000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YYYYYYJJJJJJ D ANY PROPRIETORIPARTNF.RIFXECUTIVEj N NIA OFFICER/mEMBFREXCLUDED? u below Evidence of Ing=ance EXP (Any one person) TONAL &ADV INJURY VTJCAE 977K955A-13 9/1/2013 9/1/2014 R S 2,000,000 BODILY INJURY(Per person) S BODILY INJURY(Peraccidont) $ 886766140 9/1/2013 19/1/2014 VTRXUB 920SA105-13 19/1/2013 19/1/2014 X rARx LIMITS l VTC2RuB B203A71A-13 9/7,/2013 9/1/2014 E.L. EACH ACCIDENT F,L, DISEASE. POLICY LIMIT Remarks Sehedula, If more ep eco 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORILI'D REPRESENTATIVE Co11:4197604 Tp1:1694012 Cert -20287680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD X CQmMFRCIALGENERAL LIABILITY CLAIMS -MADE OCCUR GEN'LAGGREGATE LIMIT APPLIES PER; POLICY PRO LOC B AUTOMOBILE LIABILITY X ANYAUTO ALI,QWNED SCHEDULED AUTO' AUTOS X HIREDAUTOS X NON -OWNED AUTOS X ConDad X C911 Ded C AS OCCUR X EXCESS AgCLAIMS -MADE DED I X ]RETENTIONS 10.000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YYYYYYJJJJJJ D ANY PROPRIETORIPARTNF.RIFXECUTIVEj N NIA OFFICER/mEMBFREXCLUDED? u below Evidence of Ing=ance EXP (Any one person) TONAL &ADV INJURY VTJCAE 977K955A-13 9/1/2013 9/1/2014 R S 2,000,000 BODILY INJURY(Per person) S BODILY INJURY(Peraccidont) $ 886766140 9/1/2013 19/1/2014 VTRXUB 920SA105-13 19/1/2013 19/1/2014 X rARx LIMITS l VTC2RuB B203A71A-13 9/7,/2013 9/1/2014 E.L. EACH ACCIDENT F,L, DISEASE. POLICY LIMIT Remarks Sehedula, If more ep eco 1,000,000 1,000,000 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORILI'D REPRESENTATIVE Co11:4197604 Tp1:1694012 Cert -20287680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD Date.�11.1.�.-5, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform... �71%q�.A, wiring in the building of ........... ............................................................... at.... .'!`M.......................................North Andover, Mass. . ............... Fee....)... 0.1n......... L i c. No i 1.7-je.-.. b ............. . ........ E r CrRICAL INSPECTOR Check # R 7,6U (o k I ()'�f FI � 0 Ito � Commonwealth of Massachusetts Official lY Department of Fire Services .0m.Permit No. 1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank 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 HK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her into tion to perform the elec ical work described below. Location (Street & Number) ('� Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Aippropriate Box) Purpose of Building Utility Authorization No -;7-,,) Existing Service A C -Amps / flvvolts Overhead Undgrd ❑ No. of Meters New Service Amps IWI Volts Overhead D---' Undgrd ❑ No. of Meters Number of Feeders and Ampacity A 1 Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans v No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In-Elo. rnd. rnd. o Emergency Lighting Satter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners NInitiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers P Heat Pump Totals: Number " �� � ....... Tons ........ KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Sectio. o Devis te ces 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 EQ uivalent OTHER: 5 ' � - Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including 'completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains rend penalties of perjury, that the infornlatiolpon 11W application Xtrue and complete. FIRM NAME: c r LIC. NO.: Licensee: ✓ Signature LIC. NO.. �-- (If applicab , Intoe re t" in the icense number line.) Bus. Tel. No.; �1��� Address: Alt. Tel. No.: *Per M.G. c. 1 7, s. 57-61, securi wor r uires Depa ent of ublic Safety "S" License: Lic. No.� OWNER'S INSURANCE WAIVER: 1 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 PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: - Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed 0 Re- Inspection'Required ($.) ❑ Inspectors Compfets: Y l Inspectors Signature: Date: FINAL SPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co nts: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinholdRtownofinerrimac.com The Commonwealth of Massachusetts - Department of IndustriolAccidints 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/Organizatiordlndividual): Address: City/State/Zip; Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. E]'fam a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance officers have exercised their required.] 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.]r 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 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they a're 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 employees. Below is the policy and job site information. t I /l Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: z J N 0( City/State/Zip: Job Site Address: r 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 the pains and peva fes of ' ry thatformation provided above Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License and correct. 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 ofhire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 retained 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 Comm awealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M.A. 02111 Tel, # 617-727-4900 ext 406 or 1-877:MASSAEE Revised 5-26-05 Fax # 617-727-7749 wvvw.mass.goV1dia 1z Date ...... /..�'...-15-.. vo :t"`° "� TOWN OF NORTH ANDOVER e ..— _ • oc p PERMIT FOR WIRING Thiscertifies that .................................................... ..................................... !... has permission to perform S CG/ZiTY ST! wiring in the building of .............. at .....1............V %/l!�............ orth Andover, Mass. Fee ..............'...... Lic. No. .1� . �1................. ..... ... ...... . ELE ICAL INSPECTOR Check # -3 9z�7 I '10537 } lacrnwnwoal�r. a� �l jsr�¢cic�ssGts O�cial Tis; Only . Mn - / ! Qc,:vpaacy tad Fe✓ Checked BOARD OF FIRE PREEN i }Oil REGULATIONS. 11071 All wail: to Ix p:6armed in M.a_csschuscits E1=t6eal-Co6-- WCJ 527 CMR 120D {t LEa—W J-.RA'TIhrM OR SEA-TLN 0kkA2j`ON} Da:e: I 112-2. 1;7-011 City or Town of: N 0 � G M P To the Inspector of Wires: By tills app"ii-z iDu fn : m dm-si'm'i g"Lves nDii= of bis or hm intenfusu fn pt:rfo m 1ha elertd -a2 work d,—s=-Lhed below - Location (fstrmf & Nmnber) U F(A i-') m In kd - Owner or Tenant W 611`6"/1 G-'{ I o 1 a h D Trlephana Na. -1 -7 1 _ Queer's Address I U { (A- j Gr rn Is this permit in conjun fiQu with a building permit? Purpose of Buildiaig Ezist-m-" Serviez Amps / Volts New Senica Amps I Vohs Number of Feeder€'a.ndAmpaci€p Location and Nat¢re-of Proposed Electrical Work: '�UV41 rY �. IVa Yrth A -h& VGv` T Yes No (CheckA-pprapriate Bot) UtMty Authorization No. Overhead ❑ Undgrd El No. of m tern Overdiead ❑ u dgrd ❑ No. of meters A P0/q Q"�-' 'T - [pry ' 'i V ,n .. ,.t , sL-_rte— No. afRecessed Lemxinafres No, of Cell Snsp- (Paddle) Razes o. of n. Transformers g`TA o. of aim Outlet; U. ofHot Tubs Generators KVA TMla ofLvrusnaires S4FiT1I3aIFi?pool AhaveEl - ��- area- Qrd a. o ergency , tm-w Bane 1 Ya. of Receptar3e Outlets No, of O l Burners ' IFY,. U ARY. No. of zones lNo. of Switches No_ of Gas Bm'ners o. of Detection and 5nifia1J:v-z-Device= No, of Ranges No.•of Air Conal. ToiaL Tons jin. oAle Devices f rfmg No. of Wast --Disposers Mbn-tF-mmP Totals: Iitntber Tons Na. of Sel€-Cone Detestioiilllt Devices `o. of Disbwashers SgacelArea Heating KW Lost ❑ u Q O#her Cauaene ction No. of Drpers Heating Appliances KW Se -u�unty systems:, of Devices orE divalent No. of Water Heaters No. of No. ofNa_ s Ballasts ata Wirin- Na afl3evices orE trivalent No. Hydromassage Eatlitubs Biu: ofvM©tos-s--* ,; .- ---Total HP Telecommunications Wi``�11i12-• No. o€Devices orE uzvala3.t r.J14--n aG=1=zae a>rm t 8 0,;-,= re?raraa b3' Inc lnspectoT off &=' &=, $stimated Value of Blectxicai Wow: (Wben required by rrunicival policy-) Worx to S-br - lns =tions to be Trq=sted is accor3aa:: with IydBC Rile 10, and upon campletiou- LN90RANCE C0Y-f3UGEz-T.lalcss waivei. by tlae ovm�, ria permit for the performance of el=#rical Woik may isle unless the licrosae provides proof of liability imsurancz including "compl--Led op✓rraafxon" ca-Yerage or its substantial equivalery.- The m1arsi_mea cellules that such coverage is isforce,and•ba:s exhibited pzoof of same to the permit issuing oliice. CsECK 021B: INSURANCE J�j BOND E] Olum ❑ (� ~ify.) I =}; tutder fkE pairu and enuffres of pes juin', that the infonnagan on this aFica:ior: is b ue and campy - FIRMNANFE: v f n( G L.IC. NO.: I q71-.. G Iacensee: jj�-fewv %p Signatsrie LIQ NID.: j �� G (filappiieablr, osier "ez8np!" in the irerl " se rranbc,- lax )j Bus. TeL No. O4 2TL2 Address: �GGI%7I N' 200 YV �b�. Vlr g�l�Q� Alt TeLNo.�6`Pe *MG1, c. 147, s.-7-51, work enquires i?epart7rient of Ito Basel`'S" Lids,;: Lir. Igo. CO OWNER'S I?`ZSi7R N- W I am owner ffiat- th5Liceasee doss not have foe liability Tnam-ance coverage normally r,#re i bylaw. Bymy signor --low, I bei-eby r -carve Tbis remr,'remmt I m foe (check ane) [} owner • E1 07mae s a.g ; OwnerlA•e ent Sipatare Telephone No, Department Of Pty lic Safety . a= One Ashburton Place, Rm 1301 Boston, Ma 02106-1613 License: S - License Number: SS CO 001359 Expires: 07/22/2013 Restricted To: 00 r viviotI ii"jC- . STEPHEN B COPPOLA 4931 N 300 W PROVO, UT 84604 Tr. no: 396.0 Keep top for receipt and change of address notification. DPS -CAI t, 40PJ•09!10-,PSG/DBSL`ICEIgSESPAPE,^�,F/` 11 ;p., \ .../IGC. "t^Pl7t/!9?.C✓YIU:EIGCtft, .� I! :YXY.(.�G!du��b if W DEPARTMENT OF PUBLIC SAFETY c S - License Number. SS CO 001354 Expires: 07/22/2013 Tr. no: 396,0 S -License: VIVINT INC STEPHEN B COPPOLA 4934 N 300 W PROVO, UT 84604 /J -- DIG SAFE CALL CENTER: (888) 344-7233 Commissioner a Location (03 No. �2 4 S— Date lb - 6, y 3 OfHO^TM TOWN OF NORTH ANDOVER .. 9 Certificate of Occupancy $ ',s''•'°' tt�' Building/Frame Permit Fee $ ad J �C MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �a Check # i r 16771 tAp(�-' Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING N BUILDING PERMIT NUMBER: ,r-- DATE ISSUED: /® d4 � r SIGNATURE: zo Building CommissiAe-r/InEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ia3 e\ ow, 10, 1.2 Assessors Map and Parcel a ( Number Number: 3 Parcel Number iilMap < 1 o rR n � p �?e/�. 1.3 Zoning Information: Zoning District Proposed Use j �;3 PU Address for Service 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Signature Front Yard Side Yard 2.2 Owner of Record: Rear Yard Required Provide Required Provided Required Provided Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record -L 3Urb« Name (Print) j �;3 PU Address for Service nam Q(�— Signature Telephone 2.2 Owner of Record: Nam6 Print I Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: A \ License Number Address )'< ^�-- Signature , `� �� Z 0YV Telephone Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1 Oct Company Name 1 l 4 Registration Number �1►�I6 Address 2 4 0*491 Expiration Date Si nature Telephone M M X z O X v m I o. O z M 90 O Wn r ic r v M r ^z V/ SECTION 4 - WORKERS COMPENSATION (M.G.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 it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check aII applicable) New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICL46L USE ONLY 1. Building C� o (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) I O� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 (p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , 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 SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ',1— �,A C - ,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 Print Name ,r ----. Signature of Owner/Agent NO. OF STORIES \ 0\ 6 l 02 Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TI1vIBERS P12ND 3RD SPAN DIN ENSIONS OF SILLS DIrvIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECT ED TO NATURAL GAS LINE NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-954 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: O AV, e�`� C (Location o Signature of Permit Applicant 1.o b 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Afdawt Name Please Print Name: o.yl C. Location: "1 03 i���Mar� NO, City �k) to ,,Ao v-E� _ __ Phone # I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rry employees working on this job. Comnanv name: -A�- f\ R, - Address Address e City: &±4a \%k�, Phone Insurance Co. Policy # Comaanv name: Address Ctty Phone* Insurance Co. Policy •# W c- 1/) 3 v 1-5QI .,) vo3 Failure to secure coverage as required: under Section 25A or WILL 152 can lead tothe o pasitim or criminal penalties. or.mrme up to $I. and/or one years' imprisorn mt-as v¢e4.as_c b4 Realties-io3he%m-d aMDP]IAKM-ORDER mcLafineW_(,f1.Qo.DD).ajdW understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verification. / do hereby catfy under the pains and penalties of perjury that the /nrormatlan provided above is true and correct Signature Date_ � O k In 1 o? Print name Le ,,-J, F rtk n c, S . PhWe-# %Y Official use only do not write in this area to be completed by city or town officiar City or Town— PennittLicensing Building Del QCheck if immediate response is required Q Licensing i3o Q Selectman's Contact person: Phone A Q Health Depai Q Other CO M m m 0 m A y d a- d CCA Cl) 10 0 CD Cl) ZCD y CCL O �� ro CZ y O c v CD CDCL o Q� d CD CCD O CD w CA C� CD y CD d O CA >> I Co CD 3 v y O CD Z CD O CD O CD f �• dJ o C w d O c m y � =tm 0 m c7 Q yCO COdCf m 2 =r'p ra 0 ca m d?CL m� d O CCA CD -40 m y p N =r CD m 2 > co -1C42+ A �C 0 _ •-► N O y� A Nm cm 0'm JW _ a a CL as ? _�:� dip CD m N DCL 1 �� �y m CD d H H d 10� cr W O W d N dLwv m A r Cn h a� t 5 & m� CD ON O 0 o�3 zCD 0CD �� :y .W =r o CD ° m o� In • :op o x nM �, o x H p � O A. o c') -x n x o a 0N � w dH C) n Co o p- x O O x rD (D ° �! H o x z W � �, o x r � H - o n -x n x o a 0N � w dH C) n cn o p- x O O z w s in 0 IN c IN V Mv M c h r' Board of Building Regulations and Standards fp�dfr HOME IMPROVEMENT CONTRACTOP SNA 7 Registration: 108503 Expiration: 8/19/2004 Type: Private Corporation ; J N R GUTTERS, INC. Jonathon Raymond 914 Hale St. I i4verhill, 1\0% Ci 830 +.=�dninicr r�fnr. 1 `� :: ;Jlee i1697L71i41tlC�4�` �V lf.�llx'scz + BOARD OF BUILDING REGULATIONS { License: CONSTRUCTION SUPERVISOR t' 080515 Number. CS + JO Birthdate: 07/21/1965 { Expires: 07/2112005 Tr. no: 80515 i t � 1 Restricted: 00 KEVIN M FRANCIS ' / 31 LAWRENCE ST (. _ HAVERHILL, MA 01830 Administrator • l _ ap L UIPUbal `Free Estimates Fully Insured GUITERSy INC. "Your Home Improvement Specialist" AcuTrERS, INC. ll Types of Home improvement AU Type-, of Homo �Mprvveloent Seamless Gutters • Vinyl Siding,and Trim Work www.jnrgutters.baweb.com Haverhill, MA: (978) 372-4088 114 Hale Street, Suite 204 Nashua, NH: (603) 595-2272 Andover; MA: (978) 475-3723 Haverhill, MA 01830 Portsmouth, NH: (603) 433-1811 Woburn, MA: (781) 937-4212 Manchester,NH: (603) 666-5502 Boston, MA: (617) 423-3559 Toll Free Nationwide: (800) 966-9238 Toll Free Mass Only: (800) 552-0030 Fax: (978) 372-0360 PROPOSAL SUBMITTED TO a 4r Mice PHONE, „DATE: & Barbara Ste11a 978-682-5443 9/11/03 STREET JOB NAME R e CITY, STATE, and ZIP CODE A R r3 (R .nfil JOB LOCATION ARCHITECT JOB PHONE NC j3ropofse hereby to furnish material and labor - complete in accordance with specifications below, for the sum of: ly t ro Payment to be made as follows: dollars ($ ! j. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation Authorized LK� from specifications below involving extra costs be ��Lf /la!i �..i` will extra only upon written orders, Signature /��.// N : ! ��T�'• 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 Workmen's Note: this prop Osa'I may be Compensation Insurance. withdrawn by us if not accepted within da s. _ y. We hereby submit specifications and estimates for: J -N -R WILL STRIP SHINGLES FROM SAID BUILDING AND DISPOSE OF IN A LEGAL FASHION. WE WILL BE APPLYING AN ALUMINUM DRIP EDGE. AROUND THE PERIMETER OF THE ROOF., THEN A 15 LB. WEIGHT FELT PAPER WILL BE APPLIED TO ROOF DECK. THE SHINGLES THAT WILL BE USED GAF 30`YEAR TIMBERLINE ARCHITECTURAL DESIGNER STYLE. (CUSTOMER WILL HAVE THE CHOICE OF THE SHINGLE COLOR). ANY CARPENTRY WORK WILL BE AN EXTRA CHARGE. ,ANY ROOF BOARDS.THAT NEED TO BE REPLACED WILL BE AN EXTRA CHARGE AT THE COMPLE'T'ION OF THE JOB. THE JOB SITE AREA WILL BE CLEANED ON A DAILY BASIS. ANY REMAINING OR STRAY NAILS WILL BE PICKED UP USING A IIAGNET. THIS IS OF COURSE TO PREVENT ANY INJURIES FROM HAPPENING. J -N --R ALWAYS COMPLETES THE JOB IN A TIMELY, EFFICIENT AND PROFES91ONAL MANNER THAT `OUT .-?F,RFORMS APZZ; -, I TRULY PUT FORTH EVERY EFFORT TO PROVIDE CUSTOMERS WITH THE HIGHEST QUALITY STOCK AND PROFESSIONAL SERVICE. PRICE INCLUDES FEET OF ICE AND WATER SHIELD. AS AN AUTHORIZED GAF INSTALLER WE CAN OFFER YOU THE SMART CHOICE SYSTEM PLUS WARRANTY WITH EXTENDED UP FRONT COVERAGE, ENHANCED PRORATA COVERAGE AND TRANSFERABILITY AT NO EXTRA CHARGE. 01tteptance of Propo.5al - The above prices, specifications and conditions are satisfactory and are hereby accepted. You authorized to do the work as specified. Payment cy��."� will be made as Signature outlined above. Date of Acceptance: Signature 1 NORTIf 1 BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION - a Permit NO:^/ Date Received 40 Date Issued: 9Ss ATED t IMPORTANT: Applicant must complete all items on this page LOCATION IllDa PROPERTY OWNER_ MAP NO: PARCEL: WA /Print ZONING DISTRICT: Historic District yes no Machine Shop Village ves no TYPE ,OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ne family ❑ Aoition ❑ Two or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer v zl ///iii u//, -5V Iddentification Please Type or Print Clearly) OWNER: Name: 1341,0,4e ga,� Ph( Address: Aa 11;?d1 'I za CONTRACTOR Name:Aw awp�� Address: I'd,, 90112 �/ Supervisor's Construction Licens Home Improvement License: hone: Llz'D e: 0"70 Exp. Date: 1 7 / ,9S-�/ Exp. Date: �7- q���� //0- -;�d 15— C311 12-el�6 ARCHITECT/ENGINEER zy-e!E Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ ;5-191) 6 FEE: $' ®� r Check No.:/�.� Receipt No.: 73�� NOTE: Persons contracting with registered contractors do not have access to the guaranty fund ASignature of Agent/Owner ignature of contracto Q e 4 _ TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Issued: Date Received IMPORTANT: Applicant must complete all items on this page LOCATION _ 'Print. - PROPERTY OWNER -- Print 100 Year Old Structure yes. no MAP NO: _ __ PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no .TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: A&Irace• CONTRACTOR Name: Phone: _ Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner SIg nature of contractor Plans Submitted ILJ Plans Waived ❑ Ce,•tifie`J Plot Plan ❑ Stamped Plans ❑ I d ^t, - Plans Submitted ❑ Plans -Waived-❑ Certified Plot Plan ❑ .Stamped Plans ❑ TYPE -OF SEWERAG&DISPOSAL" Public Sewer Tanning/MassageBody Art ❑ .....Swimming Pools ❑ Well L Tobacco Sales ❑ - Food PackaginglSales ❑ Private• (septic tank, eta_ = Permanent Rumpster on -Site ❑ THE -FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE. REJECTED DATE_A_PPR.OVED PLANNING &. DEVELOPMENT ❑ ❑ COMMENTS _CONSERVATION Reviewed on Signature COMMENTS HEALTH COMMENTS Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date - Driveway Permit DPW 'I ow;z Engineer: Signature: -- Located 384 FIRE DEPARTtI:ENT Temp Dump's er on site yes.. no Located bt'l24,Mair Street Fire Departmer'ifsignatu"re/date'" - r COMMENTS Y ood Street Dim-ension.. Number of Stories: Total square feet of floor area, based on Exterior dimensions. _Total land area, sq. -ft. ELECTRICAL: Movement of Meter lo.catFoti,'niast-or service drop requires approval of Electrical Inspector Yes No DANGER -ZONE LITERATURE: =Yes No MGL -.Chapter 166. Section 21A._F and G min.$100=$1000.fin.e Nu i tb ana UA i A — (i -or ciepartment use ® Notified for pickup - Date Doe.Building Permit Revised 2010 Building Department The fol; -awing is'a list of the required.forms to be filled out -for -the appropriate permit to .be obtained. Roofivg, Siding, Interior Rehabilitation Permits Building Permit Application Li Workers Comp Affidavit Li Photo Copy Of H.I.C. And/Or=C.S.L Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster. permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract Li Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: IDoc.Building Permit Revised 2012 Location No. Check #�� r,- r, � / j u U' Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ %4 06 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ " ,//Z Building Inspector v_ C � 0 0 Z N p O C o• r.L �• N �0�, <v� Q Cr o CD =r CD (DD O ou CD CD CO N• CO �D � v 0 Z CD 0 0 r+ 0 CD a C CD 0 1'• m Tom_ /N Vr z i N 00-0 - -I O < CC/R O_ n CD n 0 O C. 0 � fn o � = � N. v► a0 cN � 0 0 lL C_ 0m O -IL Cl) W 0 N O (D O 2 Q O NCDa O O .C-.�o CD CD o<to O O. . O O N - N oCD rt �� a LA fD r+ Z C_ QCD N 0 CD N C � O < CL T Ln = Qq S � CCD :E ;v 00 S T c rt O T :3�. Q 3 V1 n N O 0 lD � T v v N CD N: 0 N Pm m n M 0O aCD C 00 M M p � •a 7 �' C1 O 3 3 _rt W M O D r 2 GI O C C C. 0 • y 0 N ry (DO LA fD r+ Z W :300 T O L S T Ln = Qq S T ;v 00 S T (') 3 3 Z7 m S T :3�. Q V1 n N T \ S T v v � vZ+ Pm m n M 0O C 00 M M p 7 W(CD C 0 z LA O M 3 rD W M O D r 2 0 3. it t�, � I1tf!11l fflC'Cft' !I f7 f `7 ��'jf rfVegulation ff, effj ffairs end Business Offce of Consumer A =' 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration M DENDRON & SON CONSTRUCTION LLC STEVEN HOU 6 ENGLISH RANGE RD DERRY, NH 03038 SCA • 0 2XA-05 - -'Office of Consumer Affairs & Business Regulation }IME IMPROVEMENT CONTRACTOR «� -Registration: 171254 Type Expiration: 3/1/2016 Supplement Card M GENDRON & SON CONSTRUCTION LLC. STEVEN HIOU P.O. BOX 1024 DERRY, NH 03038 Undersecret- ary Registration: 171254 Type: Supplement Card Expiration: 3/1/2016 Update Address and return card. Mark reason for change. Address Renewal Employment ` Lost Card License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid with t signature 'Massachusetts - Department of ?rb.,c Safety Board of Builo.ng Regulations and Standards (.,n•iruvtwn §upum i—r cense CS403080 A STEVEN C HIOU, 2 NEPTUNE ROAD APT 140 _ EAST BOSTON MA 02128 Carnmfssione+ 01/27/2015 SttWrA7 E DOES MOT A Mft%'1 MV OR WMjrf&y A#AEvC..q.I= OR ALTHt iVE CiOMAGE AFFMOED 8Y iME POL CU S Utow. MS COtlsiWAU OF MUPAWA 000 NO f COMSUIU I=^ CANMCT 9E"1MIEEM Us !Bili WG WSURMM- AUTMO W x...r............. TAtf3: 8't�� k iwl0�t is sn IIQQIi10lIAL ltiSU1 m. am Pb ij mot M odwwd. Ir MHO iI IM ISiA AWK �temit iule Qonditiolli at the oolk>G a�min PeielRs nay require anti mnionamoM. Abet on *As outmode d6ft not eonl<er t� to PLAWRICl"TT WS & WXA?TaA p"Im FA11 : 224 MAIN ST M ZA IM,Ma �df tA+�1bX • �elNll. 5AL8'hd. ATH 4307`43142 �' 76Hmslurrotraaa+aru �wca IIOUMA. EWPOMMOMM C68&AtBUR OMMOM M OMCIM SOA1 CCT MUCnO i UC MA MOS tlp COMS'tRUcnow M1F R P 0 HOX 1024 i-- om-1. w 03038 Cpy t liiG/ETEMRIMEit: FOAM !!= 'r1NeeRirYAAeO! L R MiOtICilRIII�I! i� ANY AUTO AM OrMu X= Gone a MROS lvmAnw Affm 3 A :IW f.iRd8,ri7uo , YM 1 L&42MP`5* 13 ,, (ILifSM3 t OMM4 TgMaiRACUANYPMC'.ERMCAU iU'71MCERTWACAtBHOiMAFFF.CIINOWORICHRSCO)eCOVRtAG& The Commonwealth of Massachusetts Print For Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: � Q, A V City/State/Zip: Are you an employer? Check Ke appr 1. 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 me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t Phone #: 49�?& riate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and 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.] 21 — 2 4� 3s Type of project (required): 6. ❑New nstruction 7. em. 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:'f Policy # or Self -ins. Lic. #: Expiration Date: 4;hD Job Site Address: City/State/Zip:Z& y AV 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 cer i un rhe pains an erlaltofperjury that the information provided above js trug and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # M 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 #: