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HomeMy WebLinkAboutMiscellaneous - 105 BONNY LANE 4/30/2018 (3)\. I 4233 Date.../.:..a...D� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ ..(.,, has permission to perform U "-.. ......................................... wiring in the building of .... a. at ..... �...'��iv u A� ........ ........... ................................ Fee... y.......... Lic. ............. ................ ELECT' Check # i 3 3 a ...................................... ..".\.......................... North Andover, Mass. � C �_ . M ....................... RICALINSPECCOR Cor nnic' '.?health Of Massachusetts :1-56al Use Oi y =.T Departmeoit -f Fire SLrvices Permit No. _ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 (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: City or 'Town of. It/G a9�JClit7yr 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)_ /GS Owner or Tenant (meq , F-.e,Kc 4 Telephone No. Owner's Address 9 % Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building--Dlie_( [ t'✓t9 Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: V / �-<- ati /fv% 71",6 Com letion o the olio . tabl b d h b i No. of Recessed Fixtures wrn No. of Ceil: Susp. (Paddle) Fans e m e wave tens ector o Wires. No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool ove ❑ n- [j 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 No. of Detection and Initiating Devices No. oftRanges No. of Air Cond.ons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number I-- `- I Tons -"--"' IKW "­ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal [:1 Other Connection No. of Dryers No. of Water Heaters KW Heating Appliances KW No.o No. of Signs Ballasts ecuritysystems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: Na of Devices or Equivalent OTHER: Attach additional detail if 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:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: ,2S �G,2 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: O ��/�><� r ' LIC. NO.: 'f"945-121-5 Licensee: ��'cG,� e/ d16 Signature LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.:�%� Address:_/1,oAt l�,4Vf/fI �,.,A 5 7— Alt. Tel. No.: YE -920"- 2 OWNER'S INSURANCEWAIVER: 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: $ 'kN2 2339 Date ..'r� . .......... ' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... .........14. ...... ....................... has permission to perform .. ........ ............ ........................... wiring in the building of ................................................... at ... .......... :................. ........... ;'4/4- ........ . North Andover, Mass. Fee.'� ................. Lic. No;. ......................................................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts D rr ncnf o r.r.tc N.._ �,9 rnQ J Pubic �j�v BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200C-r.c,.cr a r.. O...aad�� ]/90 (1.a.. 1.1.1a) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All vorh to ba perarn+td In accordance v Ah the Has ,.nusene Electrical Cads. 527 CMR I2:00 (PLEASE PRINT IN INK 08 TYPE ALL 12 FOFLUATION) ) Date -511-016 City or Toad o- 'j To the Inspector of Wires: Ira undersigned applies for a permit to perform the electrical work described below. Location (Street 6 Number) Owner or Tenant ('�41Z 6, �-,QC.0 �✓ Owner's Address Is this permit is conjunction with a building permitz Yea ❑ `, No [2- (Cheek Appropriate Boz) Purpose of Building ,, s Utility Authorization NO. EU Ling Service Amps / Volts Overheadd ❑ `,�Un grd ❑ No, of Meters New Service Amps / Volts Overhead -�- ❑ Undgtd ❑ No. of Meters limber of Feedars and Ampaeity Location and Nature of Proposed Electrical Work r No, of Lighting outlets No. of Hot.IubsTool Ho. of Iransformers �y No. of Lighting FixturesAbove In- Suia»ing Pool rnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets UO- Of Oil Burners No, of Emergency Lighting Battery Units No. of Switch OUtlets No. of Gas Burners FIRE ALARMS No. of Zones No. of RangesNo.of Air Cond. Total Np. of Detection and tons Initiating Devices No. of Disposals No. of HO1Cs Total Total No. of Sounding Devices No, of Dishwashers Space/Area Heating rw No. of Sel# Contained Datectlon/Sounding Devices No. of Dryers He:ting Devices IK Local ❑ I'Atnicipal Other No. of Water Heaters KWNoy of o. Connection❑oz Si s Ballasts Low Voltage Lorin r No. Hydro Massage Tuba No. of iiotozs Total HP OTiiFR: INSUP-MCB COVEU=1 Pursuant to the requirements of Massachusetts General Laws / I have a current Lia Insurance Policy includingCompleted equivalent. iESi I have submitted valid Operations Coverage or its substantial If you have checked YES.Plaasa indicate the type ofrcovera a oof of be checking this othe appropriate- opr ❑ No . � g Y 8 ppropriate.bos. INSURANCE ❑ BOND ❑ O=R Cl (Please Specify) -TU - Estimated Value of Electrical Work $ i�S Gi� piracion at Work to Start Inspection Date Requestedz Rough Final , Signed u.Aerthe penalties of perjur;: FIRli NAME J �j ,' �( ' cf-0- U C 4 LIC. N0�_ Signature N0. Address t�GL/ Bus. el. No. -Alt OW2�3tcS LNSURANC LAI t �,- aware thaC the Licenses does not have the •inseuraitce coverage or rs su s uncial equivalent as required by Haasachusatts Caneral ws� , .nC that my signature on this permit application waives this requirement. Owner Agent (Plewa check one) Telephone No, pWa2 FEE S6- Signacure oj-0 ner or Agent 11 Location /",) ;� No. 1�ql � Date TOWN OF NORTH ANDOVER fo Certificate of Occupancy $ b'•^"''t�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # 0,� -'10 17U27 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: > �� SIGNATURE: Building Commissioner/IREREtor of Buildings Date — Q SECTION 1- SITE INFORMATION 1.1 Property Address: /r�,�' annu �n Assessors Map and Parcel Number 1.2 j 0a.0 octtiv Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ae al V)CIA /� 6- /.3o 4 . Name (Print) / G { Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement /Contractor Not Applicabllee� ❑ Registration Number Address Expiration Date Signature Tele hone O z M 90 0 ic M _r A� Y SECTION 4 - WORKERS COMPENSATION (NLG.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 buildiApermit. Signed affidavit Attached Yes ....... V No ....... ❑ SECTION 5 DesciA tion of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 14 UJ 1 SECTION 6 - FSTIMATRD CONSTRUCTION COCTC 1 iatf�'6e✓5 Item Estimated Cost (Dollar) to bet3F Completed by permit applicant ICTAL USE.Q.NLY 1. Building 7 ©,j (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 3 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in alLnl=rs relative work authoriz by this building permit application. 2i l Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS 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 I n 9 /. y u 2 d N r• Q y 40 _ cm ID E C CL= ` O d G � � co cm 3 C O N = m 'CD • a = Cos N O O 'Em � m O :av m N m "' Q O coa N •� CD G tr m z O `O w C Q m CD ` O = C = m C N f - y o .. _ ui W • LL �G O �" C T � = •= � z �E v o N o o � a 40 CD g COO 'M� z CL _ ce EM � O t-- .2 .2 Q:. = m F. a� O E CD o � Z O CL O CO D C C C CIO O E m m •m O O CL _� CD »-- R: ® � 03 0 e_cv o a O C w d O CDZ O d C i � C c CLh a, ck U)o O w J iy w° U w O w aG ii O U w cn —cu w a O rZ °�° c� tv G w w w� O cin i ojW o cn /. y u 2 d N r• Q y 40 _ cm ID E C CL= ` O d G � � co cm 3 C O N = m 'CD • a = Cos N O O 'Em � m O :av m N m "' Q O coa N •� CD G tr m z O `O w C Q m CD ` O = C = m C N f - y o .. _ ui W • LL �G O �" C T � = •= � z �E v o N o o � a 40 CD g COO 'M� z CL _ ce EM � O t-- .2 .2 Q:. = m F. a� O E CD o � Z O CL O CO D C C C CIO O E m m •m O O CL _� CD »-- R: ® � 03 0 e_cv o a O C w d O CDZ O d C i � C c CLh a, o O Q� C C42 C.3 'CL OWN s :.0 v Cl /. y u 2 d N r• Q y 40 _ cm ID E C CL= ` O d G � � co cm 3 C O N = m 'CD • a = Cos N O O 'Em � m O :av m N m "' Q O coa N •� CD G tr m z O `O w C Q m CD ` O = C = m C N f - y o .. _ ui W • LL �G O �" C T � = •= � z �E v o N o o � a 40 CD g COO 'M� z CL _ ce EM � O t-- .2 .2 Q:. = m F. a� O E CD o � Z O CL O CO D C C C CIO O E m m •m O O CL _� CD »-- R: ® � 03 0 e_cv o a O C w d O CDZ O d C i � C c CLh a, The Common wea!(h o�,Wussach usrns Drparrmrnr cf (ndusiria(rlccidtnrs ` _ � Otflca o(lnvesll��doas 600 Washingron Street Bosron, HOST. o? 111 —Y0rkcrs' Com pc n s a tion tItsv r n c c {(floarit I am a nom<owncr performing all work myscl(. am a so'c propr(ctor and havc no Otic any. Cac Working peCiCr _ I sm ,n cmploycr providing workcrs' compcns+tion (or my cmplovccs worktng on tnls loo �. t am a sol< propri<tor. Qcncr�l cont(ctoolrc of homcowncr (circ/c onr� and havc htrcd tllc con�acwn I:s�.<^ �< - Nc rollowtng workcr-s compensationp n .A ^N ort,, i tit 01ct73 r <1 c%n Ittd to tAt imp0%inon of tnminll p<nluiu or 1.,,�rr Io ,Itvrl tortrltI II t(gvi(to vndtr St<non 13 of ,,,ICL nom, r„ri ,mpnlonmtnl II -cll lI brit pcn#llitl in Int form% of t STO► WORK ORDER Ind I not Or 110000 'Coy npr or .n., nI„mt n, In IJ or Ior`.Iro to Ia JAt OR1ct of Inrt%A(tuonl tr JAI OIA for tortrtgt vIt, lno n, I do nrr(Of rrnify under rhr yain7 and yrnohiu of perjury a/ the in(OrMaflon proridrd gborr IJ trw( and tory(^ 0atc t 112 "� G - j,gn�tvrc _ Phone t S 4 g ) Dnni nils( orGt„I v)I onl. Jn AM -rlt( in IAII Irl% to be complticd by ciry or (own orflcill „n or :o n n ,nrl� .I �m m,o�,,, rr,ponir :i rrC�:rrd rinr' � !— pAonc I .. C.. Ion:,t� ptr:on M I ► ��� CORD 4000 OOUM. HUNG v1W F ME • DOUBLE GLAZE N�Ior�iFuwon AROON FILLED' LOW�EY. I Owd 97."T% nwwigin 6orpy S&OVS ww dfPV4 on Your ip0mg. aqr Wel-must �t�d �i���. t or mon lniormatlonu ld l(W)WSWA=34 SWAN NPAC'I Web .sit I www,nfro.wg. 0,50• • ., . 0,57 0,49 . vwl►Hry itlpulw► m W►►O ta"s t1. onlort» M ►sb a HFPtC "6"Os I / ►►fi "im4onminW BMJ i v�1►PKNk ?to" •w+wrmtti/ iw A CORD CET >r (761)273-3200 1on4corso Insurance A94ncy 63 Cambridge Street P.0- 11,01 1502 Burlington, NA 01603 41GAID 1331 Crafton Street Worcester, MA 01604 ICA (761)273-0400 IL OATS (161.4'00mT) 04/2S/2003 ONLY AND CONFERS NO RIGHTS UPON THE CERTIIIT&—r~ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURERA: Penn-A114rica Insurance Co-npany INSURGR1: Am4rlcan Home Assurance Compan INSURER C: INSURER 0: INGURER G: I"t rLxK !c5 Ur INSURANCE LISTED BELd HAVE BEEN ) SUE ME INSURED NAMED AlOvE FOA TRE POLICY PERIOD iNOTS4TE0. NOTWI HS ANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CCNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY EE 18SUEO OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES OESCRISEO HERON IS 3UBJECT TO ALL THE TERMS. EXCLUSIONS AND CONOMONS OF SL'CI• PCLJCIES. AGGREGATE L)M�TS SHOVvN MAY HAVE 17=_EN REDUCED BY PAID CLAIMS R I TYrG OF IN3URANC6 POLICY HUMeaRDA ( MlDOrY'7) TE ZM LIMTS OEHERALL:ADIUTY tAC162394918IND 03/10/2003 03/10/2004 EACHOCCIJpRENCE .3 2,000,000 X COAIMEACL1L GG•VERfAALL�LIABILITY fIRG DAMAGE ;My one 1,1) i 5 0, 0 0 0 CLAMS MADE I X ; OCCUR MED EXP (M7 one wicn) 7 S .000 A L_.J 6 AMPLE CERTIFICATE FOR INSURED AOOITICNAL INSURED; INSURER LET'(ER New England Sash a.+♦4+�++...1++�+++.+♦++.4....41+.....+++.r.� ♦+♦..4..4+++♦.•...aa+...+4.................. +. �.+..+♦+.♦*.+4++4++1+.4..4++ ++.+•+++++++...4.++..f..44+++. 50� - 9 q3 - (2361�) F.L. EACHACCOGNT I I S00 , 00_0 E.L. OQEASE • EA EMPLCYF s S 0 0 , 000 I.L. 01o"E POLICY JWT ! $ 5 0 0, OO U eHOVLO ANY OF TNG A60Va OESORisfo POLICIij iE CANCELLEO OEFORt TMi EXrIM SIGN DATE THE,"OF, THE /SWING CCM/ANY RILL SkC-CAYOR TO MAa. In . OAY3 WRITTEN NOTI:a TO T -IE CERTIFICATE HOLDER NAMED TO T4E L11T. I QUT FAILURE TO MAIL 3LCH NOT)Ca 9Nay I• ILAOC49 NO O0,IGAT,0N OR LIAD41. YT OF ANY KIND UPON THE COMPANY, IT3 AGENTS OR REPR63evTAn,1(3. hn Bohacorso PeRSCN.AL8ACV IWLI 0, 000 GG4ERAlA0L7RG0ATE 13 2 , 000, 000 G"'L AGGRGGATE LIMIT APPUELS rCR: POLICY A LOC I PRODUCTS • COMPIOR AGG i I n C I n G A AU-TOMOdLE LIABILITY ANY AUTO COMD111ED SINGLE LIMIT Na acCJenU i ALL OWNED AUTCS BOD:L'I INJURY (FWae,sm) 3 SCHGOUIb AUTOS H:REO AUTOS 5OOiLY INJURY (Par axJan:) NONOw1+E0 ALTOS rROPG.ITY �AMASE I (GW aGCtlent) G ARAG6 LIASII-rrY AVTOONLY - EA ACCIDENT 3 ANY AUTO OTHER THAN EA ACC I AUTO ONLY AGC f , EXCE3e LIAZIUTY P OCCUR CLAIMS MAGE EACH OCCURRENCE I AGGR;.;ATE 1 i )EDUCT!M f RETENTION S = WORKER3 COMP&M11ATION AND0 GMn OYERV LMILITY BE DETERMINED 04/29/2003 04/29/200.1 TO YL.7.I;Ts ER -__-- 6 AMPLE CERTIFICATE FOR INSURED AOOITICNAL INSURED; INSURER LET'(ER New England Sash a.+♦4+�++...1++�+++.+♦++.4....41+.....+++.r.� ♦+♦..4..4+++♦.•...aa+...+4.................. +. �.+..+♦+.♦*.+4++4++1+.4..4++ ++.+•+++++++...4.++..f..44+++. 50� - 9 q3 - (2361�) F.L. EACHACCOGNT I I S00 , 00_0 E.L. OQEASE • EA EMPLCYF s S 0 0 , 000 I.L. 01o"E POLICY JWT ! $ 5 0 0, OO U eHOVLO ANY OF TNG A60Va OESORisfo POLICIij iE CANCELLEO OEFORt TMi EXrIM SIGN DATE THE,"OF, THE /SWING CCM/ANY RILL SkC-CAYOR TO MAa. In . OAY3 WRITTEN NOTI:a TO T -IE CERTIFICATE HOLDER NAMED TO T4E L11T. I QUT FAILURE TO MAIL 3LCH NOT)Ca 9Nay I• ILAOC49 NO O0,IGAT,0N OR LIAD41. YT OF ANY KIND UPON THE COMPANY, IT3 AGENTS OR REPR63evTAn,1(3. hn Bohacorso 2 1 U) It Q'o p O Z wQ 0 _D T) r— z� fig' W (� N c c� L > 0 Z Y r e o ' C O N c 9 Z10 ° c I u E < l « '"tea g mss^ c _ Iv �•�,� t� to �I O'L'` ro a r^� :3�cSOc$ � j M L m N n Z J y U, Ct O a O w Z z M Y — .� _ p cn n a x LU I� o W o a j v .� w . N v cd U O l J N O O N a Q r 2 1 U) It Q'o p O Z wQ 0 _D T) r— z� fig' W (� N c c� L > 0 Z Y r e o ' bI E n N c 9 Z10 ° c I u E < l « '"tea mss^ c _ Iv �•�,� t� to �I O'L'` ro a r^� :3�cSOc$ I M N c . � e ocs Z10 ° E < l « i W ba CL CC ro a r^� Z m N n Z U, w Z z M Y — uk 0 0' ' z I� o W o a j v w . N iS .r l r Main Office: Branch Office: 1331 Grafton Street 1 Worcester, MA 01604 508-792-9181 •800-300--'17274 THIS CONTRACT made the ,oc day of in the yeaP_?_QC23 between New England Sash, Inc. and 978 - G 85 - 96? 9'8 9;78 c, 6033 (HOME OWNERS) (HOME PHONE) (BUSINESS PHONE) of /Cl3 S tsenAim V LAI //J. AtopoV ie / M A /01a 4 S (S EET) (TOWN) (STATE) (ZIP) As used in this contract, the words we, us or our refer to New England Sash, Inc. and the words you and your refer to the customer. We agree to furnish all labor and material necessary to �Ilowing deseWbedkvindows at: -SA M� DEPOSIT WITH ORDER ❑ CASH CHECK# BALANCE DUE ❑ CASH IrrINANCE You agree to pay cash according to the terms shown above or, if your credit is approved, to sign a note provided by us for payment of the amount due. You also agree to sign a completion certificate upon completion of the work. If you fail to make payments when they are due, then we may immediately stop work. We may choose to not start work again until you are current with the payments and we feel secure in obtaining the remaining payments. If there is any stoppage of work due to the preceding, such delay shall automatically extend the date of substantial completion. Payments due and unpaid under this agreement shall bear intdrest from the date payment is due at the annual rate of 18% or at the maximum legal rate, whichever is less. In the event that we incur costs or expenses in collecting such payments due and unpaid, you shall pay such costs and expenses including reasonable attorney's fees. In addition, you understand that by failing to pay according to the above terms, the seller may have a claim against you which may be enforced again stour property in accordance with the applicable liens laws. The installation will begin on or about 60 W S and will be substantially completed on or about — It is understood by you that the following contingencies could materially change the estimated completion date stated above: customer's inability to obtain or qualify for ncing; inclement wether; strikes or other labor disruption; non-availability of materials; acts of God. " We represent that we carry Workers' Compensation and Public Liability insurance in the amount of $100,000-1,000,000. ALL RESIDENTIAL CONTRACTORS AND SUBCONTRACTS ARE REQUIRED TO BE REGISTERED WITH THE MASSACHUSETTS BOARD OF BUILDING REGULATIONS AND STANDARDS, UNLESS SPECIFICALLY EXEMPT FROM REGISTRATION. INQUIRIES CONCERNING REGISTRATION SHOULD BE DIRECTED TO: DIRECTOR, HOME IMPROVEMENT CONTRACTOR REGISTRATION, ONE ASHBURTON PLACE, ROOM 1301, BOSTON, MA 02018 (617) 727-8598. CONTRACTOR OR SUBCONTRACTOR IS OBLIGED TO OBTAIN THE FOLLOWING PERMITS: N<=S 2EP IM ?_ .L_ •+_n 117 IF WE DO NOT OBTAIN THESE PERMITS, AND YOU OBTAIN THEM, OR IF WE ARE NOT REGISTERED WITH THE BOARD OF BU!LDING REGULATIONS, YOU WILL NOT BE ENTITLED TO OBTAIN ANY BENEFITS FROM THE GUARANTEE FUND ESTABLISHED UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 142A. ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED THE GREATER OF ONE-THIRD .OF THE TOTAL CONTRACT PRICE OR THE ACTUAL COST OF ANY MATERIAL OR EQUIPMENT WHICH HAS TO BE SPECIAL ORDERED OR CUSTOM MADE, WHICH MUST BE ORDERED IN ADVANCE OF THE COMMENCEMENT OF THE WORK, IN ORDER TO ASSURE THE PROJECT WILL PROCEED ON SCHEDULE. NO FINAL PAYMENT MAY BE DEMANDED UNTIL THE AGREEMENT IS COMPLETED TO THE SATISFACTION OF BOTH OF US. YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER, WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF, PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU OWN THE ABOVE PROPERTY AND THAT YOU AGREE TO ALL OF THE TERMS OF THIS CONTRACT. YOU ALSO ACKNOWLEDGE THAT YOU HAVE RECEIVED A FULLY COMPLETED COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION AND THAT YOU HAVE BEEN ORALLY INFORMED OF YOUR RIGHT TO CANCEL. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. IN WITNESS WHEREOF, the �partie!yhave�their names this 7-A da of in the year )o Signed Signed Ne L ' MAR TING REPRESS E OWNER Sinnprt Accepted: New England Sash, Inc. By AUTHORIZED SIGNATURE TITLE V_ Signed -71'L OWNER r Total Units: Double H. P. Glass GlassGrid N r' F indow Color: Material: 1 Double Hung Units: We do not do any painting or staining. We are not responsible for conditions or circumstances beyond our control including condensation resulting from or due to pre-existing conditions. Our limited warranty is herein incorporated by reference. 2 -lite: 3 -lite: ^— Installation: _!J / pC ` ='Picture r Units: Total Contract: Sales Tax: Price: Hopper Units: 'Sliding Units: Awning Units: 1 -lite: 2 -lite: Casement Units: "—'-- 1 -lite 2 -lite: -3 -lite: '4 -lite: 'Total Bay/Bow Units: DH / CS 3 -liter-- 4 -lite: ---5-lite: Garden Windows: 3 -lite!-- 4 -lite'' -5 -lite: -- Deposit With Order: .295 1 tr0 Exterior Finish: Roof Soffitt Total Projection: --- Knee Brackets:-Y-4il•- Entry Doors: Steel Fiber Style: Add Deposit Due Date: Storm Doors: Alum W. Core Style: Sliding Glass Doors: # `—� Color: Balance Due On Delivery:Z9 3 S 1 c3c if Capping& N - # UP Additional Notes: n y -r 1n AM AWQE H j_6 / N' O til 'tj my /V • _Tn -41 E LL GV/A/ PJ S _M H41/E AP ]4q0lfg=_�± Re 3-y-� S / L< 1�lJ�D [1 Llev� .- DEPOSIT WITH ORDER ❑ CASH CHECK# BALANCE DUE ❑ CASH IrrINANCE You agree to pay cash according to the terms shown above or, if your credit is approved, to sign a note provided by us for payment of the amount due. You also agree to sign a completion certificate upon completion of the work. If you fail to make payments when they are due, then we may immediately stop work. We may choose to not start work again until you are current with the payments and we feel secure in obtaining the remaining payments. If there is any stoppage of work due to the preceding, such delay shall automatically extend the date of substantial completion. Payments due and unpaid under this agreement shall bear intdrest from the date payment is due at the annual rate of 18% or at the maximum legal rate, whichever is less. In the event that we incur costs or expenses in collecting such payments due and unpaid, you shall pay such costs and expenses including reasonable attorney's fees. In addition, you understand that by failing to pay according to the above terms, the seller may have a claim against you which may be enforced again stour property in accordance with the applicable liens laws. The installation will begin on or about 60 W S and will be substantially completed on or about — It is understood by you that the following contingencies could materially change the estimated completion date stated above: customer's inability to obtain or qualify for ncing; inclement wether; strikes or other labor disruption; non-availability of materials; acts of God. " We represent that we carry Workers' Compensation and Public Liability insurance in the amount of $100,000-1,000,000. ALL RESIDENTIAL CONTRACTORS AND SUBCONTRACTS ARE REQUIRED TO BE REGISTERED WITH THE MASSACHUSETTS BOARD OF BUILDING REGULATIONS AND STANDARDS, UNLESS SPECIFICALLY EXEMPT FROM REGISTRATION. INQUIRIES CONCERNING REGISTRATION SHOULD BE DIRECTED TO: DIRECTOR, HOME IMPROVEMENT CONTRACTOR REGISTRATION, ONE ASHBURTON PLACE, ROOM 1301, BOSTON, MA 02018 (617) 727-8598. CONTRACTOR OR SUBCONTRACTOR IS OBLIGED TO OBTAIN THE FOLLOWING PERMITS: N<=S 2EP IM ?_ .L_ •+_n 117 IF WE DO NOT OBTAIN THESE PERMITS, AND YOU OBTAIN THEM, OR IF WE ARE NOT REGISTERED WITH THE BOARD OF BU!LDING REGULATIONS, YOU WILL NOT BE ENTITLED TO OBTAIN ANY BENEFITS FROM THE GUARANTEE FUND ESTABLISHED UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 142A. ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED THE GREATER OF ONE-THIRD .OF THE TOTAL CONTRACT PRICE OR THE ACTUAL COST OF ANY MATERIAL OR EQUIPMENT WHICH HAS TO BE SPECIAL ORDERED OR CUSTOM MADE, WHICH MUST BE ORDERED IN ADVANCE OF THE COMMENCEMENT OF THE WORK, IN ORDER TO ASSURE THE PROJECT WILL PROCEED ON SCHEDULE. NO FINAL PAYMENT MAY BE DEMANDED UNTIL THE AGREEMENT IS COMPLETED TO THE SATISFACTION OF BOTH OF US. YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER, WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF, PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED, BY TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE SIGNING OF THIS AGREEMENT. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU OWN THE ABOVE PROPERTY AND THAT YOU AGREE TO ALL OF THE TERMS OF THIS CONTRACT. YOU ALSO ACKNOWLEDGE THAT YOU HAVE RECEIVED A FULLY COMPLETED COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION AND THAT YOU HAVE BEEN ORALLY INFORMED OF YOUR RIGHT TO CANCEL. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. IN WITNESS WHEREOF, the �partie!yhave�their names this 7-A da of in the year )o Signed Signed Ne L ' MAR TING REPRESS E OWNER Sinnprt Accepted: New England Sash, Inc. By AUTHORIZED SIGNATURE TITLE V_ Signed -71'L OWNER r MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.313 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address Policy Number: Type Loss: Date of Loss: Claim Number: 10/13/05 EY S 2005 I.) /EFz GAELFRENCH 105 BONNY LANE, NORTH ANDOVER, MA 01845 0723547 Water Damage 10/08/05 221918 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139, Section 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 Date ... .�..... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas iinsu in the buildings of . h.. at Fee. /, � Lic. No.....� 11 Check #( r. 4594 ./. ... zze-.X:_. .......... North Andover, Mass. .......................... GAS INSPECTOR N is-. MASS APPROVAL # MASSACHUSETTS UNIFORM APPUCATIO F-55 (Print or Type) P. fi��1 V"G �/ , Mass. Sate—2 Building Location —!0 h (00 S �A->- r G New ❑ Renovation Q GASFITTING �1 o"vu r ' Permit Owne.'s Name G(A Y/1C��n Type of Occupancy��— Replacement ❑ Plans Submitted: Yeso No Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET CK Corporation 103C MIDDLETON, MA 01949 [ Partnership Business Telephone 978-774=2760 [ Firm/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which metes the requirements of MGL Ch. 142. Yes IX No ❑ If you have checked yes, please Indicate the typee coverage by checking the azpropriate box A liability Insurance policy 13 Other type of indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does nct have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit zpplication waives this requirement. Check one: Owne{ Agent ❑ Signature of Owner or Owner's Agent hereby certify that all of the details and information 1 have submitted (or entered) in above ayucaticn are and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit' for this be in corn f with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the taws By Tof License: Plumber gnature o moer or rtter Title Gasfitter Master License Nurnber 3785 pty/Town Journeyman APPRaVED( t NL (1 MENEM Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET CK Corporation 103C MIDDLETON, MA 01949 [ Partnership Business Telephone 978-774=2760 [ Firm/Co. Name of Licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which metes the requirements of MGL Ch. 142. Yes IX No ❑ If you have checked yes, please Indicate the typee coverage by checking the azpropriate box A liability Insurance policy 13 Other type of indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does nct have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit zpplication waives this requirement. Check one: Owne{ Agent ❑ Signature of Owner or Owner's Agent hereby certify that all of the details and information 1 have submitted (or entered) in above ayucaticn are and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit' for this be in corn f with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the taws By Tof License: Plumber gnature o moer or rtter Title Gasfitter Master License Nurnber 3785 pty/Town Journeyman APPRaVED( t NL (1 Date . Y...��:.. C J 1 \ 0 L.o Li' L / •°,;•,��coL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that...................... has permission to perform plumbing in the buildings of ..:...:�...,�_:- at ..,%'��... , North Andover, Mass. Fee .*'0 ...... Lic. No.�.'?! ; f�- ........ . PLUMBIN7 INSPECTOR v WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ,eT%'✓ N/1dY� Mass. Date �� oU Permit# Building Location IAS- W.-/ ,c 4,c1 L Owner's Name CJ,; Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No I"4 ---- FEATURES Installing Company Name/w,'e /c (570u one: Certificate Address ! �f S� ✓«-� � f�/7J S7-1 / U Corporation r' �f�c- `�SS�ig X Q l�A /? � 1-] Partnership Business Telephone 1 �U//'���/ —5160 _ I�m/Co. Name of Licensed Plumber .? �—/ /7 �/ ( �BC,/ t ----- INSURANCE COVERAGE: I hAe a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes Er-' No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Qom- Other type of indemnity 1=) Bond ❑ OWNERS 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: Slona[ure of Owner nr C)wnwr's Anwnt Owner ❑ Agent ❑ i nereoy ceniry tnat an of the aetaiis 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 the permit Issued for this application will be in compliance with all pertinent provisions of the Massachusertate Plumbing Code and Chapter 142 of the General Laws. By 'r Title City/Town APPROVED OFFICE USE ONLY) Type of License: Master �^ Journeyman ❑ License Number —;:;' -/o 4? 20 �N`r/ z Z z W U) J > O Y _ Q Z w w U) z u) Q (!> IF < Z F U) z CL Q . W w U) U) = W !Y F-- U Q W U) Y Q U) u- Z a Z F - U Q Z w 0 W Q W Q Q U) Z Q Q U) znmo a: a: O LL. Lu = Q= o O o= t- � o O Q z Y z w Q Cr z Q >~ m U) g Q z z o o �, w 1-- o x cn Q p 3 1Q- W u_ 0 D a Q3: aC m O SUB-8SMT. BASEMENT 1ST FLOOR.. / 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR 11 - i-7EEE Installing Company Name/w,'e /c (570u one: Certificate Address ! �f S� ✓«-� � f�/7J S7-1 / U Corporation r' �f�c- `�SS�ig X Q l�A /? � 1-] Partnership Business Telephone 1 �U//'���/ —5160 _ I�m/Co. Name of Licensed Plumber .? �—/ /7 �/ ( �BC,/ t ----- INSURANCE COVERAGE: I hAe a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes Er-' No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Qom- Other type of indemnity 1=) Bond ❑ OWNERS 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: Slona[ure of Owner nr C)wnwr's Anwnt Owner ❑ Agent ❑ i nereoy ceniry tnat an of the aetaiis 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 the permit Issued for this application will be in compliance with all pertinent provisions of the Massachusertate Plumbing Code and Chapter 142 of the General Laws. By 'r Title City/Town APPROVED OFFICE USE ONLY) Type of License: Master �^ Journeyman ❑ License Number —;:;' -/o 4? 20 �N`r/ 4'_ X -d-7 Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .../46 5&-r— u � , S�/rtlie e3 ................................................................................. has permission to perform ......71n U.R , TY ��� SYS e-05: F ........................................................... wiring in the building of .................. ........................................ `� . , North Andover, Mass. at .............. ���.........../Q� �?!U!U ...... i ................ Fee...:l ............... Lic. No.�'.�..�a,��............................................... ......... ..... jse- ' 00/97 ELECTRICAL INSPECTe S --j 9 k wove Check # 7446 (�onmonwaaLth o�a�aca Official Use Only c� �7 Permit No. 7ZI-Sl� �L.1eParfmar+� o�,}ire �arvica� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS[Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort: to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPEALL INFORMATION) Date: („ - D City or Town of: . A) Aru 00\_)CJ11_ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention tQ perform the electrical work described below. Location (Street & Number) I O J W Owner or Tenant E_-c-tl fr &,N C, Telephone No. M 6 11 9111 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Utility Authorization No. Overhead ❑ Undgrd p Overhead ❑ Undgrd ❑ 1.) I,' Q 1 tr» o Com letion o the following No. of Meters No. of Meters C 011U r 11kf d r^ 1--I 1- La ffyl A IN ' S Li S-reM be waived by the In ector of Wires. No. of Recessed Luminaires No. of Ceil: Susp• (Paddle) Fans r of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ n- ❑ Swimming Pool g rnd. rnd. o. oUnits Emergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o eteng D an Initiating Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Dis osers p eat ump Totals: um er ... . . ... ons ............. o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal EJ Other Connection No. of Dryers Heating Appliances KW Security Devic s or Equivalent No. o atero. KW o o. o Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP a No of Devices or Equivalent No. of Devices or E uivalent OTHER: Attach additional detail ifdesire..,4 or as required by the Inspector of N':res. t Estimated Value of Electrical Work: ° (When required by municipal policy.) ' Work to Start: A S Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERA E: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: P�—C S�CtIY`1'r� Scr'UCCPS LIC. NO.: 5� 3 Licensee: .;K Signature s rZL:3 LIC. NO.: (Ifopplicable. enter "e em t" in the licende num er line.) I , Bus. Tel. No.: J S9d Address: (? L 1 �T�+e- pits , /JH 4309 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS C C D U %' 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 a ent. Owner/Agent PERMIT FEE: $ �S Signature Telephone No. MWE LA 0 m j7. kv 0, tz N r1i 71, m m CC) c K3 m p - : ';VF ;" - 'DTZ i I V) r M Z m m C/) ;Q0 o z z m Zm M (D m C13 —;L z 0 2f ch. c . C cp -4 z m (nr— =r CL ch 0 1� rrr Cf) m X co 'D fD Cr ID M L4 Lnc U) C) Lj CL cn > —i m;o cn Cn m X : o CD 3> C. C) se C-) m -4 < m z 'n. to 0 cn z , --i �-4 V1 01 0 (D cy) =L M> V) to C) c� m 0 -n m C) onz cc) 4 Ln ;o N, C: C CD 71! 1 o (n z 0 m > 0 to > > •W Z -n C-1 M m Signature lic :N7 - d 1 February 9, 2010 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Re: 105 Bonny Lane, North Andover Foundation As -Built To Whom It May Concern; Sullivan Engineering Group, LLC Civil Engineers & Land Development Consultants Enclosed is a copy of the Foundation As -Built Plan for 105 Bonny Lane for your records. If you have any questions please feel free to contact me. l ly Y urs, ivan Cc: Annecrest Builders Gene + Anne Saragnese, Owners 22 Mount Vernon Road — Boxford, Massachusetts 01921 — (978) 352 -7871 -Phone — 978 352-7871 - Fax V) _j UJ U Q O Q J X Z co (oO� mmo QLoi � r - X �\ FQ- Z -H L'o O r - z CL 2 is w WA fA CO CHI CHEWI CIS _INE (H. WL) H.W.L. ELEVATION = 108.5' L=193'± PER RECORD PLAN OF BONNY LANE LOT AREA 58,890 S.F. + 48.9' 185'± W 2.6 7' 2.0 v x. CONC. UNDA TION 3.0' 12.0' 0' o . 23.67'cv 107.7' vi I CERTIFY THAT THE FOUNDATION SHOWN WAS LOCATED ON FEBRUARY 9, 2010 BY AN INSTRUMENT SURVEY AND THE LOCATION COMPLIES WITH THE ZONING SETBACK REQUIREMENTS IN THE R-1 DISTRICT. RECORD 0 WNERS- ASSESSOR'S MAP 62, PARCEL 52 EUGENE & ANNE SARAGNESE 105 BONNY LANE NORTH ANDOVER, MA 01845 ZONING INFORMA TION: ZONING DISTRICT. • R-1 * * WATERSHED PROTECTION DISTRICT MIN. BUILDING SETBACKS: FRONT : 30 FEET SIDE : 30 FEET REAR : 30 FEET J50, 8UF or 01, loN g20NF +i N E � rf R MARk co J O� Q Q o � QJm 0.� W Q � � 250, z ZONE rR DIS 1Sq 4qkE NCE 325' NO Z01VE FRo1W A H RGE kE ,#1115 BONNY LANA' POEMA77ON AS--BU&T PL" OF LAND LOCATED IN NORTH AND 0 VER, MASSACHUSETTS (ESSEX COUNTY) PREPARED FOR GENE & ANNE SARAGNESE SCALE. l' 40' DATE.• FEB. 9, 2010 PREPARED BY SULLIVAN ENGINEERING GROUP, LLC 22 MOUNT VERNON ROAR BOXFORD, MA 01921 (978) 352-7871 Date. /'o I- — 0,,,,,,o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..................................... has permission to perform — .'�,J'-Y ...................... plumbing in the buildings of... .. .................... . at. North Andover, Mass. ��INSPECTOR . . . . . . . . . . Check # P If 9 855� ra MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER, MASSACHUSETTS / Building Location D '�' 36 U ti b(/ , Owner rt) 6 !J55n rA v �A) Date 171A Permit # Amount Ne Renovation 0 v Replacement Plans Submitted Yes No FIXTITR Fc (Print or type) ) l N Installing Company Name }�/y%� b Check one: Certificate ❑ Corp. Address Z)re- C Partner. b Business Telep - j Firm/Co. Name of Licensed Plumber: Insurance Coverage: In ca a type of insurance coverage by checking the appropriate box: Liability insurance poli Other type of indemnity ❑ Bond Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance signature Agent F1 I hereby certify that all of the details and information (or en ed) in a o application are true and accurate to the best of my knowledge and that all plumbing work anform JIFeRr der Issued for this application will be in compliance with all pertinent provisions of the k Cod pter 142 of the General Laws. By: igna o r Title of Plumbing License City/Town rcense um � Mast Journeyman (oFFIcE usE oNLY 11APPROVED f The Commonwealth of Massachusetts r Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organiza6on/Individual): Address: City/State/Zip: �fQ�j� J f7/j ' Phone #: 9 �w Type of project (required): 6. [] New construction 7. El Remodeling 8. E] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other + __....__.,A .....,.....e M=rr worl'ers" compensation policy mfomvatton. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. l Insurance Company Name:% Policy # or Self -ins. Lie. #: 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 ofIl for insurance coverage verification. I do hereby ce n r the p s and a es of pe r t the information provided abo is tr a and correct Si atur Date.: Pho e#: O tial 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 #• e ou 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).* 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• [1 We are a corporation and its required.] officers have exercised their 1 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.] Any aPPlicant that checks box 4l must also iill out the sPcaor nee^ , Type of project (required): 6. [] New construction 7. El Remodeling 8. E] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other + __....__.,A .....,.....e M=rr worl'ers" compensation policy mfomvatton. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. l Insurance Company Name:% Policy # or Self -ins. Lie. #: 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 ofIl for insurance coverage verification. I do hereby ce n r the p s and a es of pe r t the information provided abo is tr a and correct Si atur Date.: Pho e#: O tial 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 #• J, , 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 4 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 t 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 pernait 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. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5-26-05 wwvv.mass.govldia Date ........:/, ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .►-.�.�. This certifies that ..... �..i .......\::-::......_.....................::..-t..'............................ has permission to perform - -- - --� �- ..........................:.....:................................... J / wiring in the building of ..... ::..: . ' f........:............................. at ..., .......:: :.t- ....-.."/.. ... .................... . North Andover, Mass. If Fee> .....:.............. Lic. ............. .. ECTRICAL INSPECMR Check # 9213 _ ConarrwnweaGth o� ii/aseaclue Official Use Only v cc�� cc77 Permit No. aLJeParEmen� o� fire �ervice� �, ............... . 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 Co C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYP,F ALL INFORMATION) Date: ' /o City or Town of: l�"% �f /Z To th 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) /4,S ,(fie• u4C y g�A�✓j ' Owner or Tenant Owner's Address No. Is this permit in conjunctio with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Geci 14� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number ... . . Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Serity Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts I No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of El ec ical Work: (When required by municipal policy.) Work to Start: Q Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: 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 Ur BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: lQu .nJ M % LIC. NO, -7Z Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the license number line /� / Bus. Tel. NO. . 117v Address: 3S •�t,i t.+�.e oZ lZ>� o/�j,f—�C fd Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires l5epartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 gwww. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j� Please Print Legibly Name (Business/Organization/Individual): l�C/-� 6em_z�.1 Address: rl,;';Plb� w / 4_ i -L X-6 City/State/Zip: Phone #: �'7�- 74 G • 2/ PS ' Are you an employer? Check the appropriate box: 149 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. ❑ 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 10Electrical 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. 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r^/f� /c{-� _-7 Policy #nor Self -ins Lic. #: (�` 7��2j Expiration Date: r Job Site Address: N City/State/Zip: 40, ��D•�-�� 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 th ains andpenalties ofperjury that the information provided ab ov is true and correct. C7 QYIAi11YP' l/ Y / T1..4�•, 1__,01 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date ... .......... i` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ..'I, .e ... `.r. (-J:-:............ in the buildings of at .............. . North Andover, Mass. Fee . 3 U Lic. No. 70 7 t. ..... -.. �- /� ........ . / GASINSPE OR Check # / / 727 G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date JUNE 23, 2010 Permit # Building Location 105 BONNY LN. Owner Tel# BILL 781-820-1457 Owner's Name GENE SARAGNESE Type of Occupancy RESIDENTIAL New W1 Renovation❑ Replacement FIXTURES n Plan Submitted: Yet No[:] Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6628 (OW F]Firm/Co. Name of Licensed Plumber or Gas Fitter ROBERT GRENHAM INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have'''"'c�����------e'''"cked yts, please indicate the type coverage by checking the appropriate box. A liability insurance policy �d 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 m, Knowieage and tnat all plumbing work and installations performed under the p for this a p ti n will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 14 VoftGe ral La . By Type o cense: Title tuber • -Gas fitter S nature of Lice sed Mdmber or Gas Fi r • -Master License Number City/Town • -Journeyman APPROVED (OFFICE USE ONLY) MM Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6628 (OW F]Firm/Co. Name of Licensed Plumber or Gas Fitter ROBERT GRENHAM INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have'''"'c�����------e'''"cked yts, please indicate the type coverage by checking the appropriate box. A liability insurance policy �d 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 m, Knowieage and tnat all plumbing work and installations performed under the p for this a p ti n will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 14 VoftGe ral La . By Type o cense: Title tuber • -Gas fitter S nature of Lice sed Mdmber or Gas Fi r • -Master License Number City/Town • -Journeyman APPROVED (OFFICE USE ONLY) 2 Silver Ledge Road, Newbury, MA 01951 Office: 978-462-4331 • Cell: 978-973-2366 • Fax: 978-462-5528 • email: ifix@comcast.net June 9, 2010 Inspector of Buildings — Town of North Andover 1600 Osgood Street. North Andover. MA 01845 Re: Residential construction at 105 Bonny Lane, North Andover, MA Dear Building Inspector: On June 8, 2010, 1 visited the residence at 105 Bonny Lane in North Andover to observe the new construction. During my site visit I observed that the structural framing; which was substantially complete, had been constructed in general accordance with — or met the intent of — the drawings which I had stamped. If you have any questions, please feel free to contact me. E J Date. 6 . � .� /�... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �7SSACHUSE�t 4 This certifies that X. :� .&......r .... has permission for, gas installation4...,t4� in the buildings of ..--'....................... at ��7, ... 90-7A7 ....� 74-r-�, North Andover, Mass. Fee.,f5Y ... Lic. No........... ................. ` '..... GASINSPECTOR I Check # d 35ir 7252 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FTFrI NG (Type or print) Date—,(,a.-14111d NORTH ANDOVER, MASSACHUSETTS Building Locations �d �✓ 1y 4-5-A I /�' �A r' A P / r'I d-7--G� Owner's Name New ❑ Renovation Replacement Plans Submitted 0 Permit # Amount $ (Print or ?Yj Check one: Certificate Installing Company Name it' /J (��1/YI? J 2z: ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE " C ck o I have a current liability Insurance policy or it's substantial equivalent. es No If you have checked ,yes, please indicate the type coverage by checking the appropria X. 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 v mitted (or entered) n ove app ' ti re true and accurate to the best of my knowledge and that all plumbing work and ' ation�ss rmer ermit Is e f is application will be in compliance with all pertinent provisions of the Mass us s Sas Co� hapter 1 f General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) ire of Li Plumber Fitter Master Journeyman sed'Plumber Or /Gas F.i r � � lc nse umber w � U � CA H W QQH v1 O a d V F F ` Td x W CC w C p W > w W - E" U `� a F G(+ w 1 d w w > w � F z F a e o o w o O x w 3 C7 U cd > o co• w 6. H o SUB -BASEMEN T B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLO OR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or ?Yj Check one: Certificate Installing Company Name it' /J (��1/YI? J 2z: ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE " C ck o I have a current liability Insurance policy or it's substantial equivalent. es No If you have checked ,yes, please indicate the type coverage by checking the appropria X. 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 v mitted (or entered) n ove app ' ti re true and accurate to the best of my knowledge and that all plumbing work and ' ation�ss rmer ermit Is e f is application will be in compliance with all pertinent provisions of the Mass us s Sas Co� hapter 1 f General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) ire of Li Plumber Fitter Master Journeyman sed'Plumber Or /Gas F.i r � � lc nse umber The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Washington Street Boston, M4 02111 www mas&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 box- 1.7 ox: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. ❑ 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 ---iW out me 5-IMMberew stlo%vmg their work=! compcusation 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-contractorsand 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 ofperjury that the information provided above is true and correct Signature: Date.: Phone #: Fi al 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 6. Other Contact Person: Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information an d 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 co=npliance with the insurance coverage required." Additionally, MGL chapter 152, §25CM 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' comp enation 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 reques*.: d, not the Department of Industrial Accidents. Should you have any questions regardiiv g 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 burn leaves etc.) said person is NOT required to complete this affidavit. . The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesfitgafions 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 6.17-727-7749 www.mass-gov/dia