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Home My WebLink AboutMiscellaneous - 111 CHRISTIAN WAY 4/30/2018 r -- 111 CHRISTIAN WAY 2101104.D-01 30-DOOO-0 1 1 1 1 1 f + r , i LOT i 48 LEACH FIPLC +} i { 4. EXITING FND 1" Ca r 1 JIM!"Y 7HAf )I Ii- t I ,C `a�r:�i�T.'t.t. raALLCU A`� SkM'r4 f tHia IILA146,f:�kVtti',�)1 iJ ►�,r'1 �:J{Fa/aAi f t �� TF1+ '�YJ�1�, s a.EVATItx:S PLANS1��Vd1\-G SJ�r��J ��AC'--. tib CSE -- - t '' AS BUILT t , Ii EOUSE C iTL£T I tJ:73 - r{ r C 1 Ir t ! 5 T ME T i BU.QC Chi ST OJTI`ET I$J:Q .��. �� I':tet�T' ��:L L�Lt'� I4FAJY T RUST i U-" INLET I7 6C} UATF 6 157 c I D+DX afrLET �(_F 1=40 I79.jv _ END FIELD I7clOb i F7RFPAREU BYti i j f Deslq Ff3gineers Assoc, P Cr" 0-Cox 516 z Norfl-1 Andover, lvi 7ss, Opp-45 t Location �-- tj Date NORTH TOWN OF NORTH ANDOVER Certificate of Occupancy $ — • Building/Frame Permit Fee $ sATNus t� Foundation Permit Fee $ _ C Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ r, TOTAL $ �_ Building Inspector o Div. Public Works s� PER3trr No.—O ` APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP INO. /Q (/ LOT NO. +y�"'� O / ?O 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE — ZONE / ` I SUB DIV. LOT NO. ! ✓ I LOCATION /�/!/� PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES / SIZE OWNER'S ADDRESS ` t ��• BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �y SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES- SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION ^ LAND COST SEE BOTH SIDES EST. BLDG. COST D 1 EST. BLDG. COST PER SQ.PAGE 1 FILL OUT SECTIONS 1 - 3 ' PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED CT ` �C� C BUILDING INSPKCTOR SIGNATURE OF O O AUTHORIZED NT F E E OWNER TEL.x PERMIT GRANTED CONTR.TEL#19 CONTR.LIC.+f H.I.C.! �y� I i � I A • � Gti2�i��i � � 1 } 1 � I 1 I tel/✓�?/y�%'v-- .2x y 17, IL �, . ) C``p ,zt x ��t, 'Y• J /_Jj%/AS��NAF��ai1G►SRsvGLW - � L'. -_ H,91MAA 1__WNT�,G±t�NTRACTORS REGISTRATION '~ r R�Ot sono aa:nd Standard t ra, Mass b�sette. 02108 NOME_ IMPRQV 1'. +UNTRAGTpF _ lE.x Registry irat on <26/97 hype INQIWID ." 4� .. i i N r9 LO I .d I � I w d ►GGCzce O H O V REGISTRATION and Standards I om 1301 02108 p ~ V7 H F i~� o.� 010/26/99 --------------may Q +�-� o � aas � y ai r I �\ ✓Ile'�oo/rawo/ta/ealQ�r o��maditdelld y m a I HOME IMPROVEMENT CONTRACTOR Registration 114800 I Type - INDIVIDUAL Expiration 10/26/99 a, d DENIS BOUCHER CONSTRUCTION DENIS P. BOUCHER G�+ain o &yqW STEDMAN ST. 13 a y oma', I ADMINISTRATOR CHELMSFORD MA 01824 H N V O S '1-• A. V Qum}H•� �.1,;�. •�,�, )a. � x OR T/y dTown of t - Andover * - dower, Mass., 1998 0 z .9 LAKE C0 C MICHEWICK - ,9 AOA',T E S E BOARD OF HEALTH PERMIT D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........................................... ... .................. .. t�`'4.1��t�., ................................................ Foundation has permission to meet.. ........ buildings on .....1/I..........C.G4k1.,S7?'.-7A.N..........W.d. y... Rough to be occupied as ...........:.... .......fm2i! ...... .. f Chimney provided that the person accepting this permit shall in every respect conform to the terms of the ap cation on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration_ and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STAR Rough ............................... . .......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be .Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. PERMIT,7110. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. C PAGE 1 MAP NO. I LOT NO. 12 RECORD OF OWNERSHIP '.DATE BOOK '.PAGE ZONE SUB DIV. LOT NO. L �I LOCATION -�+ PURPOSE OF BUILDING OWNER'S NAME f EC T- Mucf O NO. OF STORIES SIZEEVCJK� OWNER'S ADDRESS (11 C r.l - 0 I - BASEMENT OR SLAB , F1n 1 7qY�� tiedy&r- ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES -SIDES REAR " " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY / IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LANDl WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER rNO IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST o _-- PAGE /PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 ' EST. BLDG. COST PER ROOM \ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO.4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS \ PLANS MUST BE FILE�D/AND APPROVED BY BUILDING INSPECTOR DAT FILED BOARD OF HEALTH N TURE OF 0 OWPJgk OR AUT RIZED AGE T F E E V PLANNING BOARD PERMIT GRANTED _G • L2 19 _ BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH L1�` CONCRETE _ B 1 2 I3 C'r CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY-WALL V UNFIN X 3 BASEMENT AREA FULL x FIN. B'M'T AREA _ '/ 1/t s/ FIN. ATTIC AREA n NO BMTI'T FIRE PLACES L C FNIFurnA,,F- HEAD ROOM MODERN KITCHEN v 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE 7( _ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE 1 IP BATH (3 FIX.) GAMBRELMANSARD TOILET RM. 12 FIX.) L FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK L SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST ?*� PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS IL O B'M'T 2nd ELECTRIC lsf 13rd I NO HEATING WOOD STOVE INSTALLATION CHUALIS I rU1. Ill LIU. Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove Rosso A. New Used 11 RMQ OLL -ka C w B. Type/radiant Circulating - C. Manufacturer Lab.No. T -001 Name/Model No A40 DE L A X, 5w Collar size 6' Dimensions/Height A►�" Length `s Width Chimney A. NenrExisting Y-S � B. Size(flue area) h — - C. Other appliances attached to flue(Number and flue size) D. Prefab(Manufacturer—name an type) E. Masonry/Lined Flue liner 71-F- Unlined ityp•&manufacturor) F. Height'(refer to diagrams) cap ( avEi,tci o�R 10I 112't MIN. kt . MIl�. ' t,o' I D' 3 fv11 N. f MIN. 1$`I MIN. . (FUEL/A5H . + ACG�5551� HEARTH IL CHIMNEY HEIGHT Hearth(non-combustible) A. Materials ed/V 6 f5TE E B. Sub-floor construction - C.D/VC 119►r-FIE C. Minimum dimensions(refer to diagram) Clearances and Wall Protectlon(see stove installation clearances chart) A. Type of wall protection provided �'nn�C F �= B. Clearances(refer to diagrams) 57/06 3. /3 K-- e5l"K 0roaP 5 i t FIREPLACE CORNER WALL/CENTER 13 cap factory-built chimney C roof support support bracket B connector pipe non-combustible wall protection • - •••• A connector overlap A ' A i woodburning p stove .� tenon-combustible �1 floor protection i 12" y i 12'. I . Figure 2109.4 Figure 2109.4 STOVE INSTALLATION CLEARANCES Combustible t/:"Asbestos Millbopro Concrete:Masonry Spaced Out 1 " Stove Components Material Spaced Out 1 '' 2. 'Foundation wall 4'Brick Veneer Radiant Stove(t. 36" '- -Front Circuiating Stov24• — - -Front A. Radiant Stove 3. 36" 18• 6 18: Side!BackiTop A. Circulating Stove12" 6�• 6' 6" —Side!BackiToo 8. Single Wall 18" 12" 6" 8" Connector Pipe B. Insulated 2' 2" 2" 2" Connector Pipe C. Chimney Heignt Three(3)feet above adjacent roof and ' (Metal or Masonry) two(2)feet above any roof ridge within t0 feet.. If a damper is not included in the stove construction. 0. Damper it must be installed.in the connector pipe. 1. Front:Fuel or ash access side. 2. Non•comoustible spacers required. 3. Clearances on each side of a radiant stove with a heat shield shall be measured as if a circulating type. Note:Clearances shall be measured perpendicular to stove body. Laboratory verified test clearances permitted. 4. Thimble required for passage through combustible construction. 12 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: C7 Date Received Date Issued: /0 IMPORTANT: Applicant must complete all items on this page LOCATION C n n S l 1 afl N. A RA J e✓ _-} Print PROPERTY OWNER 110�a�r-t k� Print MAP NO: b 1flT PARCEL:,ZONING DISTRICT:_Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building iOne 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: s\-\�rCA l roo-F , -a f? cr e_ Identification Please Type or Print Clearly) OWNER: Name: TRobe r+ 'Parkcu Phone: Address: (2khA n 4�6( , � dl Sys CONTRACTOR Name: a 0 06 Phone: Address: 2 00 '�U- "b 11 S} - Sv I& Z 2 G N 0 I -A 4 e. PA M q 5— Supervisor's Construction License: C1 9 3,5b Exp. Date: f a 1 b ao I I Home Improvement License: D4 9 Exp. Date: Q 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: $ q 9 �O . d FEE: $ 0-- Check No.: /,3 7 Receipt No.: 2 :P4 S NOTE: Persons contracting with unregistered contractors do not have acce&qo the uar n4fund Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes J ,"tanning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date ..._...._........_................................_..............._...._...................._......_...................................................................---...._........................................._.._.......................................................__...................._...............................__..._..............................................----......................................................._._ Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application o Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) ❑ 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008 Location ce�/ No. r5 U Date �oRTM TOWN OF NORTH ANDOVER O: • • ow ►- .: a ` Certificate of Occupancy $ • s, , a n CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Z 1 n r Building Ins ector NORTH ' TO" of 4Andover No. i.S% Q Z _ = dover, MassLAKE ., O COC IC.WICK 7�AORATED '9S BOARD OF HEALTH Food/Kitchen PER I MIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT ''� . .....�� ....... C............ .................. ................................................... Foundation has permission to erect........................................ buildings on .. f/.C........6...!S.. ..1..`�:... . ..�.. ....................... Rough y to be occupied as.... .� .. 4 e-.. . . ..c�.�?... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough .......... ... ...... ........ ....................... Service UILDINGG IN�fiPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the' Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. � /.�,V DAVID CASTRICONE CASTRICONE ROOFING&SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO.ANDOVER MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhlp 978-374-7314 Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to famish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below scribed: f Owner's Name.....))..��.r... .:..r.. ....`.�...... ;:� r... �.k...................................................TelepJ¢one#.....�,:.�..,�...-:.:��'.�..C....... Job Address....././..I....... .�h•LJ..L.t. ....•.......�:�,�, ,t...............city..... z:....��X111 u.ir�r.:.............State.....NtA...... l Specifications: $trip existing shingles. ;j} .rt"pply new drip edge to all edges. ..................................................................................................................................................................................................................... Apply `feet ice and water shield membrane to bottom edges of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ..............................................................................................................t.;i............................................................................................ Apply felt paper underlayment. :.Install ridge vent to 4Zeroot using ,t �; "Ir shingles with a?Z r year warranty. .............................................................:........................................................................................................................................................ .Counterflash chimney. -New vent pipe flashing. a-Legal disposal of all debris. ................................................ ?.y.�.:j. . ............................................................................(................................................................ ' 1 Area(s)to be worked on: /)' .................................. ...... ....L`r::G'.p........(,.':.y a.�,{a ........i.. ..,u,;...Ar.,........ ................................. .-.. ! ......L.L '..... 'L. ..j:r:.1. .. .........l..J.e,�:,�r......��...��.,{.e............................... �G/.......................... ....... ..�. ,.... ........... . ............. ..................................................................... '..;:: .-.�...�L �. ............. .G.:.k.. .7...}:...5..: .�..r..l....:.J :1.w./...... ..:.. :..Y..w'./-..................................................................-_.__ .....-. ... Roof board replacement if necessary @ ��' /shit or `—`/foot. ........................................................................................................................................................................................u�G..Li. .............. Two Year Workmanship Warranty(Not Transferable) N)'anufacturer's Warranty as specift "by ma-ii r@ ctnrwr The coptfactor agrees to perform the work andri the materials specified above for the SUM f$.......1S.0.....`t........ V ayable..ti S Q..C/...R..........on...S.r.Payable.....r':'!.................on........... ........ alance payable on completion of'o ,_ Owner or Owners are not responsible for Property Damage or Liability wh o is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above (i.e.objects coming loose from walls,crumbling plaster,exposed nails,dust in attic or other living spaces).Items in attic may need to be covered by homeowner.All materials are property of contractor. Any dumpster placed by contractor is for his use only.Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due and payable.It is agreed that,if permitted by law,contractor shall be paid by the ownct(s)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates of the parties.The undersigned warrant(s)that he is(they are) the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s).There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,not any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:Director,Home Improvement Contractor Registration, One Ashburton Place, Room 1301,Boston,MA 02108 Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction- related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A. Approximate starting date of work...............................................: Completion date......................................................... Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. + DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). IN WITNESS WHEREOF,the parties have hereunto signed their names this...... ...day of....9,r4ltk......20.x.4...... Accepted: Signed .: Owner Signed............................................................................. Owner David Castricone,President //— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Krrvrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): AV I e M-ra I C O N S R 0O F I NC d S ID I N 6 10(- Address: NAddress: 20o S(j-1hI3 Sry2 t" Su V--V-r_ Z2 b City/State/Zip: h-OcNbo 46(L NA 0 115 4S Phone#: )-)t (p 6 3 3`F 2.0 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition workingfor me in an capacity. employees and have workers' y P Ty• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[?q Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. nn� Insurance Company Name:�1e h$(ince Co(Y1Do4iLr G1+ S&-b 3 ft Policy #or Self-ins. Lic. #: W C 9`5 a 19 (p Expiration Date: 9-Aa. 2 o 1 0 Job Site Address: I\I C�6 S+i a,) �pa t City/State/Zip:1(�. � fckk I fm 6 ri- 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 (t�he pains and penalties of perjury that the information provided above is true and correct 57p__9 . Signature: J l9 Date:/ Phone#: Lo 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#: Town. of North Andover �,n►�r,Y 4. 1 6 Ruddiug Dep4l,-tment o 27 Charles Street °' a'`J: l North Ando � . L ver, Massachusetts 01845 � � ��.�:�; (978) 688-9545 Fax (978) 688-9542 �..Jo DE131US DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris r&i.sILing from the work shill be disposed Of in a properly licensed solid waste disposal facilit., as defined by MGL c,11, sl 50a. The debriswill be disposed of in/at: Nd Facility lo.;iifion �- Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project tluough the Office of the Building Inspector, ! . itc lc'o.rrbNcrJruoctrz/C/[. r��. ,:/Ca.JdCccl�tttdeJ Eitutl'tl of l3uiltlinl, Kc: ulatiun.h andtihtnll;U'lls �;` llnardnflluildingltcgulalimSsandSt:unlmds --� Construction Supervisor Specialty License V HOME IMPROVEMENT CONTRACTOR License: CS SL 99358 Registration: 104569 Restricted to: RF,WS Expiration: 7/14/2010 Trif 270265 DAVID CASTRICONE '"' F °''Am Type: Private Corporation 31 COURT STREET tl DAVID CASTRICONE ROOFING, SIDING& NORTH ANDOVER, MA 01845 - David Castricone 200 SUTTON ST SUITE 226 Expiration: 1 211 6/201 1 NORTH ANDOVER, MA 01845 P Adminislratnr l'lllunii„ilni I Tr..~.: 99358 V I ACORD.. CERTIFICATE OF LIABILITY INSURANCE c,9/29/zoo' TM1I PRODUCER (508)651-7700 FAX 508-653-8089 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC Com eircial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW!, Natick, MA 01760 Select Ext.53389 INSURERS AFFORDING COVERAGE MAIC# INPUREP David Castr,cone Roo Tng & $Tding Inc INSURER A: The Insurance Co of State PA 200 Sutton 5'I: INSURER B: suite 226 INSURFRG; North AndUver, MA 01845 INSURER D: INSURER E. COVERAGES THE POLIGIE5 OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTP,NDING ANY 99OUIREMIrN7,1`0M OR CONDITION 01=ANY CONTRACY OR OTHER DOCUMENT'WIYH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OIT MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF$UCH POLICIES,AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. INSRDD' POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER LIMITS 1JXR� GENERAL LIABILITY EACH UCCURRENCl' $ COMMERCIAL GENERAL LIABILITY DAMAGE TPAFMISERO RL-NTEU tE CLAIMS MADE ❑OCCUR MCD CXP(Any one parson) $ PERSONAL&AOV INJURY OLNI.RA1 ACCRL""GAt1 $ OLN'L AOOHEQATE LIMIT APPLIES PER, r'NUUUC IS-COMWOP AOO S POLICY 7PRCTO LOC JE AUTOMOBILE LIADIUYY COAeBINEDSINGLELIMIT $ ANY AUTO (1-a pc idnm) ALL OWNEq AV700 BODILY INJURY $ SCHEDULED AUTOS (I'e varsonj HIRED AUTOS BODILY INJURY 8 NON•DWNED AUTOS (Pcr ac(:idenI) PROI'f=R'IY DAMACP S (Per ovidonl) GARAGE LIABILITY AUTO ONLY,EA ACCIDENT $ ANY AUTO LA AC; $ OTHER THAN _ AUTO ONLY: AGO $�^ EXCESSIUMBRELLA LIABILITY CACI I OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ 0LVVC1'119U: RETENTION S g WORKERS COMPENSATION AND WC9752746 09/23/2009 09/23/2010 xWCSTATU- OTH EMFLOYERS'LIABILITY R,LIMITS I I ER A ANY PROPRIF,TORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT s100,000 OFFICERIMEMBER tXCLUDED'? E.L.DISEASE-EA EMPLOYES 1001000 It W$ dasonbc undo SPECIAL PROVISIONS below F.L,DISEASE-Pp!ICV LIMIT $ 500,00 OTHER OCSCRIPYION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT i SPHCIAL PROVISIONS CERTIFICATE N EL N SHOULD ANY OF THF ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE YHE David C a s t r i c o n e Roofing & Siding EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 200 Sutton Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Suite 226 PUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO ORLICAYION OR LIABILITY North Andover , MA 01845 OF ANY KINb UPON THE INSURCR,1YS AGENTS OR REPRESENYATIVES. AUTHORIZED REINiESENTATiVE -..I..- Stace Brice PKG ACORD 26(2001/08) ®r ACORD CORPORATION 1988