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Miscellaneous - 114 GLENNCREST DRIVE 4/30/2018 (2)
114;GLE7NNCREST DRIVE 77210/1000.0 ./"'��� L � FILE Date. . .`._. TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING US This certifies that , . has permission to perform . . . . . . . . . . . . . . . plumbing in the buildings of . s. ... . `. . .`. . . . . . . . . . . . . . . . . . . . . . . . . . , North Andover, Mass. Fee�� S� . .Lic. No..I'W7. . . . . . . . . . . . o PiU BING INSPECTOR Check # 302 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS p _ p (y✓'r Date /7" o �z Building Location 6 ��,�t�� f4 �'% /� Permit Amount Owner New Renovation Replacement Plans Submitted Yes ❑ No FIXTURES crF Cn w a a CA A SLRELgML RASEME r IST HDCIR M FID(]R 7Z V ':M firm, 4IH Hl= 5M HDM 6M HjOCR 7M HIM 9M)N7 OOR (Print or type) n e Check one: Certificate Installing Company Name 0 C Yk ti $ fll E] Corp. Address Zfe 1 Aar-Dcx- ❑ Partner. / ,mess a ep one w� �I Co. Name of Licensed Plumber: cgI2..t/P � jo�[t T N 11 Insurance Coverage: Indicate the!pp-of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: 1,the undersigned, ama aware that the licensee of this application does not have any one of the above three insurance ignature -� Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in ab ve application are true and accurate to the best of my knowledge and that all plumbing work and in tall ions performed u r Pe t Iss for this application will be in compliance with all pertinent provisions of the Massac lambing o a of the General Laws. . By: igna ure ol Licenseaum er Type of IPlumbing License Title p. icenu City/Town se m9er Master Journeyman ❑ APPROVED(OFFICE USE ONLY AGI TOWN OF NORTH ANDOVER ° ; p PERMIT FOR PLUMBING This certifies that . . '. . . ! ff°•G• • • •j• • •� • �� has permission to perform . . . . . �-� u,` ��'• • e• plumbing in the buildings of . . . .�� r . . . . . . . . . . . . . . . . . . . . . . . . . at. . ... . . . . . . North Andover, Mass. Fee.??. ' . .Lic. No.. !3 . . . . . . . .. . . �" :�. . . . . . . /PLUMBING INSPECTOR Check # ! 3 7 7 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) J 3 7 3 NORTH ANDOVER,MASSACHUSETTS Date Building Location 114 C jk �,��_cT wners Name � � ��� ' Permit# Amount Z J^ Type of Occupancy vC'/AlGl-[^' New Renovation �` Replacement Plans Submitted Yes No ❑ FIXTURES z H w w w s O w w �- *0 0 4 z CI x a E- A a s 9 . ra A STSBgVI!1C lSr 11" M FLOCIR 3M HJOCR 4M)H j" 5M Hffit 6M HDM 7M It" SIH)HIDM (Print or type) n Check one: Certificate Installing Company Name -S' i !)P p f'e tt,6 Corp. Address 76 A,' S ❑ Partner. Business Te ep one — 99,54— / �irmlCo. Name of Licensed Plumber: 6,0 j'Q rc`�?i 0 Insurance Coverage: Indicates the tlpe of insurance coverage by checking the appropriate box: Liability insurance policy (1/( Other type of indemnity ❑ Bond ❑. Insurance Waive : I,the undersigned havZaenAnade aware that the licensee of this application does not have any one of the above three insuranc ignature Owner ® Agent El I hereby certify that all of the details and information I have submitted(or entered)in a ve a lication are true and accurate to the best of my knowledge and that all plumbing work and insta f ns performed dFr P t ed for this application will be in compliance with all pertinent provisions of the Massac tat C of the General Laws. By: igna urs o1 I-icensea Plumoer Title Type of Plumbing License 4?/Q City/Town icense um Ser Master Journeyman APPROVED(OFFICE USE ONLY \R Date....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'ISACHU This certifies that ..... ...... has permission to perform ..... ...................... Zt"*�,.,j//.-J,-../....... ............. wiring in the building of....... ..................................... at..... .;N rth Andover, fe.. Lic. ......ear. � . ..e ....... OELR,CAL ...n........ .. INSPECTOR Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services 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: June 25, 2002 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 114 Glencrest Drive Owner or Tenant Orlando and Debra Corsi Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Residential 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: Central AC installation and renovations of the first and second floor bathrooms Completion o the followin table may be waived by the Inspector of Wires. No.of Recessed Fixtures. No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets 8 No.of Hot Tubs Generators KVA No.of Lighting Fixtures 20 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 9 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total 2.5 No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained p Totals: ......... ................................................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Second floor receptacle and switch replacements 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:) Appleby&Wyman CNA 4/23/03 (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: D&D Electrical Contractors,Inc. LIC.NO.: A11933 Licensee: Douglas P.Lynch Signature LIC.NO.: 24594 (If applicable,enter "exempt"in the license number line) Bus.Tel.No.:781-932-0707 Address: 247 Salem St.Woburn,MA 01801 Alt.Tel.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: $110.00 Signature Telephone No. f i'` Date.... �� / �.. No HORT4 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SUSE� This certifies that ...... ....................................�� . ........................................ has permission to perform ..... ... .......................................... wiring in the building of.... .............................................................. at...... ......G .. .. .......... ......_ orth Andover,Mass. _ _ , -� Fee.... `.5.... Lic.No. ..�...�.. ............... (.................... '-'ELECTRICAL INSPECTOR C 7 Check # S WHITE: Applicant CANARY: Building Dept. PINK:Treasurer �•� TIM WA MUNWLAUHU1''MA.a,.A(:HUJL"113 Uthce Use only DEPARTMENTOFPUBLICS4FE7Y Permit No. 3 BOARD 0FFIREPREVEM70NREGUL4T10NN527CW 12:00 Occupancy&Fees Checked UAPPUCATION FOR PFRAffTO PERFORMELECITZICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 / (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 11q i Owner or Tenant Owner's Address �— Is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box) i` Purpose of Building S a wl t I pW Pi��l r� Utility Authorization No. f Existing Service Amps Volts Overhead 1:3 Underground No.of Meters k New Service Amps / Volts Overhead M Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work �W d e, Base Wier fc, tit%N o k1k? No.offLighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.ofLighting Fixtures ((^ Swimming Pool Above Below Generators KVA ce ground M ground No.of eceptacle Outlets D No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons i No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of+Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained j Detection/Sounding Devices No.of Dryers Heating Devices KW Local a Municipal Other • Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER Inst==Caraage Rasuat�bthetagimanatsofivf Cra�s�tlLaws thmeaomutLrblityhnranePbbcymddmgCanpl& CotrdWordsahtitiale4uvAUt YES NO Iha%esubmftdvalidptoof0fSMW1otheOTM YESNO Ifj uha%ecluiWYES,pleas mdc*thetypecfema bydxckff gthe wpcp box WSURANCE F771 BoND ED 01IER (Pleasespecify) EVilatian Date FAim&d Vater dUednc rl Wak$ WakioSW d $_O hgxx iaiD&-R4xsW Rough M��/`0/ Fera! Signed utxlaM Penalties ofperjtay. FIRM NAME Lioa�seNa Lioa>see Ro W41 J5 Sigrmne LimwNo �3 loo tc Business Tel.Na S W Gtaeta ozoZZ _ , ., 3� ��.r f � � AkTel.Na -� 1- OWNER'S MURANCE WAIVER;I am awareth itheLioasedom not $re cmratx:ewvmr,"steal etas tecgmWbyMaMftEdts Gard Laws aad�my sigtradtuemlhis pem�a�pfiatiot► this racgtasrl�. (Please check one) Owner Agent El /1 Telephone No. PERMIT FEE ., V Location �- No. Date „ORTN TOWN OF NORTH ANDOVER OL f 9 s ; ; Certificate of Occupancy $ '��s'••°•tt� Building/Frame Permit Fee $ .7 CHUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Building Inspector:` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE•IS SUED: SIGNATURE: Building Commissioneffinspector of Buildings Date SECTION 1-SITE INFORMATION ,' 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ' Map N ber• "t Parcel'Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided.. R red Provided 1.7 Water Supply M.G.LCAO. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT r 2.1 Owner of Record D 9L4'AfAo ClIMS 1 114 6716wezesi, bo. � Name(Print) Address for Service 9'79-&S-3-3700 Signature Telephone 2.2 Owner of Record: y Name Print Address for Service: r Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 09 eQ Licensed Construction Supervisor: License Number 0 .Address s Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable �G Company Name r Registration Number r Address m ' Expiration Date Signature Tele hone i ' 1 t i . i i SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) i Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result . I in the denial of the issuance of the building permit. Signed affidavit Attached Yes........❑ No.......Q SECTION 5 Description of Proposed Work(check au applicable) New Construction 0 Existing Building $ Repair(s) ❑ Alterations(s) 1� Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �2�D/ASF DA-�r�l�lUlT-`51���T 2c�cL_ ^Aj rnjsr/ & 4JAt,LS F IkCTIC4 C*(-., dUT L E"►S�B�IsE 6U�f-EGD f it.�4T SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be SEONL °"� Completed by permit applicant �E 1. Building (a) BuildingPermitFee 3 b O o• D O Multi lier 2 Electrical 00V 60 (b) Estimated Total Cost of Construction 3. Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 6 Total1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIES FOR BUII.DING PERMIT . L I, as Owner/Authorized Agent of subject property • 'Hereby authorize' • to act on My behalf,in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHQRIZED AGENT DECLARATION I, 1ruia caner! rized Agent of subject ope Hereb are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si afore of Owner/A ent Date 11111111 OEM NO, OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr 2ND 3Ku SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DIMENSIONS 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 t NORTH Town of North Andover ho Building Department 27 Charles Street . s North Andover, MA. 01845 D. Robert Nicetta SAC ,Se Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please printp I DATE ell 2-5/0 JOB LOCATION T Number Street Address Map/lot "HOMEOWNER 179- Name Home Phone Work Phone PRESENT MAILING ADDRESS004 l�.,S City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as su ervis p or. State Building( g Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-{aws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirem nts. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordanc " ,� t e provision of MGL c 40 S 54, a condition of Building Permit . Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: GAS A 5 b1SPC5,R1, 1 LA-ttA*w Pe*bc y 1V-ih -78i -9Uy--yoz3 (Location of Facility) 9 i ure of Permit Applicant l� e � Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector tA'R T_#j"*� Town of over 0 VO No. 0CL OCHiCA ErIO dover, Mass., 9' RATED H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........!P./I?ZA 0 Co. C.S I ............................................ ...... ..... ..... ....................................................................... Foundation 1!� ................... Rough has permission to erect buildmXs on ....... ......pe ' oct Chimney to be occupied as.... ........ ......... 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 a;'onstruction of Buildings in the Town of North Andover. /L9 J(C/L,57 ge PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STAR ELECTRICAL INSPECTOR C Rough L ...................................................................... Service BUILDING INSPECTOR 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. Date...... .. ` N2 , � NORTI♦ °f<�``°;•�"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSA Us� This certifies that ✓4 l ' .. ` Se R J t c S ......... .D... .......... ................... ......................................... has permission to perform ......................... wiring in the building of....o. s1"'."J'jV C o.S.t................................ at......A ....�a- �. � .PS�..... .................. . ....... .North Andover,Mass. Fee... .... Lic.No.A..D.).C...... ....�R;[Ca�L............................... ELE INSPECTOR C 76 /�5T99 :22 35.00 PAID I' f WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 1� Oilbe Use Only (�'J C114e (10mmonwetttth of MagaC4119e Permit No. V Department of Public $afetg L Occupancy a Fee Checked BOARD OF FIRS PREVENTION REGULATIONS 527 CMR 12:00 9190 Qeays blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4/29/99 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electri'cai work described below. Location (Street & Number) 114 GLENCREST DRIVE Owner or Tenant ORLANDO CORSI, JR. Owner's Address (978) 683-3720 Is this permit In conjunction with q building permit: Yes ❑ No ® (Check Appropriate Boz) Purpose of Building - Utility Authorization No. existing Service Amps s! Volts Overhead ❑ Undgmd ❑ No. of Meters New Service Amps_J %bits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work TbW No.of Lighting Outlets No.of Hot Tubs No.of Ihmtormors KVA No.of Lighting Fixture Pool Wnd. 0 lgmd.❑ Genento s • ttVA No.of Emergency LlphtlM No. of Receptacle Outlets No.of ON Burners Battery Units No.of Switch Outlets No.of Gas Burners FIRE ALARMS No.of Zones of Defection arW No.of Air Cond. Tn Nj�grp DevicesNo.of Ranges tons No.of Disposals N0.011 Pumpe Tbbnns K+ No.of Sounding Devices No.of Solt Contained No.of Dishwashers Space/Area Healing XW DeteeebnlSoumding Devices No.of Dryers Heatlng Devices ► local ❑ pAuelidpat Connection ❑Other No.of No.of Low No.of Water Neaten INV Signs' Bapasts Wkirtg BURGLAR ALARM & No.Hydro Massage Tubs No.of maws lbtal HP OTHER: TWO SMOKE DETECTORS INSURANCE COVERAGE:Pursuant 10 the requlreatents of Massachusetts gwwW Laws 1 haw a current Liability Insurance Policy WkWing Completed Operations Coverage of Its substantW puivalent. YES G NO O 1 P have submitted valid proof of tams to the OMce.YES O NO O If you have checked YES.please Indicate the type of coverage by cheeldog Me appropriate box. INSURANCE O BOND. O OTHER O (Please Specify) (Expiration Date) Estimated Vakie of Electrical Work= 544.00 /99 Work M man 4/29/99_ Inspection Dais Requested: Rough - Final 5 3 Signed under the Penalties of perjury: •• t 1 C FIRM NAME LIC.NO.y..1-- Licensee nnnAl d_A- Arnrika Mtuft UC.NO. . 12311_ Bus.TIN.No. Address 111 Morse Street, Norwood, MA All.Tel.No. OWNER'S INSURANCE WAIVER:I am aware that the License*does not haw Me Insurance coverage or He substantial equivalent as rs. qutr*d by Massachusetts General Laws. and thnt my signature on this permit application walves this requirement. Owner Agent (Please chock one) 1>.lepilora No. PERMIT PEE i 35.00 (Signature of Owner or Agent) f -76 YC rcne N° 2297 Date..`-3'"'5 .y,9......... l NORT►{ °ft"`°;•�"o TOWN OF NORTH ANDOVER p PERMIT FOR WIRING . S ,•'. CHU This certifies that-4............................................... ..................... has permission to perform.—n .................................................. `wiring in the building of................................................................................... i = at. �.` ......�. ,North Andover Mass. l Fee. . ......... Lic.NoXIIVJ........j .................. ............ ELECTRICALINSPECTOR 03/22/9915:52 90-M PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer :,.�� n:t:..• ese only -- - The Commonwealth of Massachusetts P.it No. Department of Public Safety � Occupancy S Fee Checked G� U✓ BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 heave stank) g APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK } All Work to be performed In accordance With the Massachusetts Electrical Code. S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date March' 11 , 1999 City or Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 114 Glenerest Drive Owner or Tenant Orlando Corsi Owner's Address _ Is this permit in conjunction with a building permit: Yes Q No ❑ (Check Appropriate Box) Purpose of Building Residential Utility Authorization NO. 901614 Existing Service 100 Amps 120 / 240 Volts Overhead N Undgrd l] No. of Meters 1 6� 120 240 New Service Amps / Volts Overhead ® Undgrd[D No. of Meters 1 / Number of Feeders and Ampacity addition:Small aon 200 • Location and Nature of Proposed Electrical Work Amp service upgrade and kitchen rehab No. of Lighting Outlets 18 No. of Hot Tubs No. of Transformers Total KVA Above In- No.No. of Lighting Fixtures 16 Swimming Pool grnd. grnd. L' Generators KVA No. of Receptacle Outlets 13 No. of Oil Burners No. of Emergency Lighting Batts Units No. of Switch Outlets 1 No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges 1 No. of Air Cond. Total No. of Detection and Initiating Devices No. of Disposals 1 No. of Peat Total Total No. of Sounding Devices k p Pumps Tons KW g No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connection No. of Water Heaters KW of o. o Low Voltage SiSns Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current. Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YESK] NO [] I have submitted valid proof of same to this office. YES❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. P INSURANCE a BOND [] OTHER C3 (Please Specify) Appleby & Wyman 4/99 Expiration Date Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAMED D Electrical Contrac or5 , Inc LIC. NO. A11 9 3 3 Licensee DOLgI as P. Lynch Signature LIC. NO. 249q4 Address 247 Sa 1 c-m qt. . a_ Woburn , MA O1 801 us. Tel. No.� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE-S .9 0.0 0 Signature of Owner or Agent Location No. Eate NORTH TOWN OF NORTH ANDOVER 3?O�tt`•o I•,�O F Op Certificate of Occupancy $ • _ ; ; Building/Frame Permit Fee $ ,SSAC MUstt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector 04/05/9i;, x2: PC----- Div. Public Works C PERMIT NO. APPLICATION FOR PERMIT TO I3UILD********NOR" lI ANDOVER, MA n1 u'NO. LOI'.NO. 2. RECORI)OF ON'NLRS111P DATE j BOOK , PAGE ZOAE SUB 1)1V. 1.01 NO. `rllo i \%4r LOCA I[ON PURPOSE OF HIM DING i NO.Of:STORIES SIZE v� f ()WNEk'S NAME1 OWNER'S.ADDRESS 1� n F BASF:f`IENF OR SLAB ` 1` SIZE OF FLOOR LIMBERS °1 1a-,<ST 3 ARCI IITECI''S NAME Bllll DE•R'S NAME ; G SPAN �Ot�' l 1 OIr DISIANCETONEARESFBUILDING DIMENSI(NJSOFSILLS o DIS I'ANC.EFROM SIREE1' / DIMENSIONS 01:POS IS — aX DISTANCE FROM LOT LINES-SIDES REAR � DIMENSIONS OF GIRDERS AREA OF LOT Ac—n-' FRONT AGE �� IIEIGI IT OF FOUNDATION THICKNESS 1®l ISBOILDINGNEW 'SIZEOF.F("IING X `®�( ISBUII.DINGADDIFI(N1 MAIERIALOFC111MNEY l ► I V `` IS B&LDING ALTERATION IS BUILDING ON SOLID ORTII.LED LAND CJV k G` WILL I BUILDING CORJFORM TO RE(-1 IIREMEN'I'S OF CODE IS BUILDING CONNECT ED TO TOWN WATER y��}ti:`'"` BOARD OF APPEALS AC-1-ION, IF ANY IS BUILDING CCINNECI ED TO TOWN SEWER 1CTS �' '�"``" '^ J IS BUILDING CONNEC1EDTONATURAL GAS LINE INSTUCTIONS 3. PROPERTY INFn11NIA'FION LANUCOSI' EST. BLDG.COS f s' PAGE I FILLOUrSECTIONS 1-3 EST. BLDG.COSTPERSQ.FT. EST. BLD(i.COSI PERR(X)M EI EL-TRIC METERS MI.JSF BE ON o(jTSIDE OF BUILDING, SEPTIC PERMI 1'NO. AI'IACIIE1)GARAGES MUST C(NIFO IATO5FATEFIRERE(AILAFI(N1S J. API'RON'ED ON.: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECF(l2 BtItf.DING INSPECTOR \Q \ � DA FE FILED _\ OWNERS TEIA ,^ C(N'FRA1I.b sL C(N1TR.I.Ic'If 40 SI(iNFIIRIiI)I UN'NIiR1K ) AlfFlk)RIYIiDAGINl :� ^� 1 1 1: III RMI IGRAN I HI Ii_ I k' I 'E a _ ,m•.2.,�;�y;.. -•�:p a .''-r_; DATE(M DDYY) ORD, w-1= 1�ll�r _e3118/99 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Linda J. Conserva Ins. Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9 y HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Paul Murphy Ins. Agency ALTER THE COVERAGE AFFORD99 BY THE POLICIES BELOW. - 33 Dartmouth 5t. _ COMPANIES AFFORDING COVERAGE Malden, MA 02148 COMPANY Merchants Ins. Co. of NH A INSURED COMPANY II Michael L071i B 110 Haverhill St. COMPANY C Reading, MA 01867 COMPANY r.F:y, , 4D .dWafI"i.F:iR!± . �§ MO. - ,.d :,sai�l1 N F_r t.a.i•'^'^'^•c'.Ii9 � THIS 16 TO CCRTIrY THAT TI IC POLICIES OF INSURANCE LISTED BELOW I LAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TME POLICY PERIOD INDICATED,NO i NVTHSTANDINO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED B Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI_THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR j DATE(MM/DD/YY) DATE(MM(DD/YY) GENERAL LIABILITY I GENERAL AGGREGATE $1,000,000 .. F---.._..... ---- ----—-- COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPJOP AGG $1,000,000 1�X to be issued 3/18/99 3/18/00 PERSONALSAOVINIURY E 1.000;000 -� `CLAIMS MADE OCCUR ------- SOO,000 OWNER'S S CONTRACTOR'S PROT - EACH OCCURRENCE E FIRE DAMAGE (Any one ere) $50,000 MED-xP (Any one person). s 5"000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO � ALL OWNED AUTOS :BODILY INJURY s , SCHEDULED AUTOS (Per person) I I ~' HIRED AUTOS i BODILY INJURY $ — NON-OWNED AUTOS (Per acciaeM( ___... .._.. PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY_EA ACCIDENT i ANY AUTO I _OTHER THAN AUTO ONLYI i. -_ EACH ACCIDENT $ - - AGGREGATE $ EXCESS LIABILITY FACH OCCURRFNCF S UMBRELLA FORM AGGREGATE E OTHER THAN UMBRELLA FORM E j YYC STATu !0 TR �_TQRYU% i ER__.- _-- EM PROPS MPELITY NAND INCL I EL EACH ACCIDENT $ EMPLOYERS'UAEB.ITY THE EL DISEASE-POLICY LIMIT $ PARTNHRS,EXECUTIVE --+ L.. OFFICERS ARF. EXCL. EL DISEASE-EA EMPLOYff E E i OTHER --- � I DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS I , _.e, ' .aseua._.' J`i•'.' IIei, :• .i:` �r1, fir_! rN �� ��;-„= �;•�. .c. I`c�'S_.�_._ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ORLANDO CORSI EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 114 GLENNCREST DRIVE 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. N. ANDOVER, MA BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KJND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Linda J. Conserva _. •�:... ..,, r:�,r,:• :r::::�„ •,t':�,�, .. s.t:-:r• •;1•'Sas. "^9q;d:atjjat7..p��„_ - �� ,•.�;;;ru:.':�as., •,r•:,_:..,,. i 9 ,;t_. ... ,- .F,�R• L •�::u�-i�!�i:~ r�� „., � --,�5,a 'r_-_. %a�Tr• x a .:ate •'�� - -. < � ✓fie COoa�an¢aozruea��� a�,l:��crvoae�u�el�� t p DEPARTMENT OF PUBLIC SAFETY x CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: I CS 050535 05/02/2080 05/02/1952 `' Restricted To: 00 MICHAEL LOZZI 110 HAVERHILL ST N READING, MA 01.664 /ze V�om�nan«eall�o�./lr/,aafac�zrutella i HOME IMPROVEMENT CONTRACTOR Registration 106177 Type - INDIVIDUAL a Expiration 07/22/00 M.D.N. ASSOC & CO. G� Michael Lozzi Haverhill Street ADMINISTRATOR N. Reading MA 01864 c FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT Me- OR.I'u-& PHONE LOCATION: Assessors Map Number a\01(04 0tlSci PARCEL 00 rvGl ��L,vi ,�•� SUBDIVISION E-Y l� LOT (S) 1'i rlb STREET (�' ATJVJc,ree t ST. NUMBER Gtl) OFFICIAL USE ONLY*** RECO NDATIONS O TOWN AGENTS: - CONSERVATION ADMINISTRATOR DATE APPROVED DATE-REJECTED COMMENTS TOWN PLANNER DATE APPROVED r1� DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED .�-�- DATE REJECTED SEP C INSPECTOR-HEALTH DATE APPROVED _ DATE REJECTED COMMENTS PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE i L LCAr P 4- r i r � r rN �or) �1 , r `J ;�I F . Q1(90AC�� fvknk) PC s Qr P,Y i t JOMN 5. j l l.AUKRANI C # 34311 %TES's" "A� ..ANO 3U1PvEY. c. ERFBv l=F1'IFv 7 T},E1 t AMERICAN S"HVEYrNG COMPANY C MGRit3:,GE ".�i, ti C .h _ , WAS PR P G F 77 ftUmrarC A.ve V, �c, a t, air MA^1..5� rb': j3 647 Tn d Wtirc��r� ��; ��p A___•THE LOC AT!L OF Mortgage In pectlon p!, , ;lJFlVEY 7:'. C . c Fac, y� N E E THE gE�'Oo:E A7 �C � Y flFJ s"wy . or c`,q ES. DVVFLLihC9 St�O','Jh sjEP,E��N EsUOx �i�: ..__.Pq�+C3E rlr 1. otic j` '-4 WAS IN COIAPL.IA.N E 67.1 TMF LOCAL PtL—AN GE%EREN ,tv Er• DRc,r.N PtR TO'✓ ,431,BS 7r, ^ASS'. `=`".ICA? pt' LE Z0Ni!O . ._ ,-,aVv'S-,. 1N )h IJ SAS % ✓'1 �l!C}. 1, r ,_ W EN .7 i w'T j A _ k N'*^RIIA T �' r Q " SIEC T E r,AE I•Ap a �_r7 P RC f _ - _. }.4TEG 1p r 'C3 NGA.7.GNTA; G;PAc +S.c,Npt ADC,,R S F,JR" ,=� O� -S4._E.S RECrU.'�E:V{Fr�'S GNLY),t?F 1� ExEMr�7 S.1 � - __....... FROM ViOLAMON ENIFOACEN4,'NY AC &O LaP.:"wFH Q� W -.•- _ tj•,2 F' r,;DN_S,9 L ,t r :5 ch. T.CN. QNDEAMASS 0 L Til LEV:,CrsA p Mi"'eI 0,1HE.,�r 'VeNEdDA• SEC 7 UNLESS OThERWI.S SUli,'ECT DWELL.NG UES !N ; COD ZONE - $rJ7 ,C,E; N:)7E0 CH C;H0V N HEa,LON A CON AS S.HCIWN ON NATIONAL FLG->0 I:NS:JlA.NCE RFO()RAM ;U>,-.0 C:RPAAIO'Av INS TAUMENT F,�,PVEr' INSvRANCE RaTE MAP DATEt� STR'"Wi '+ES ARE COMMJNlT`f PAN L a OR LESS r"AOM - f F<E AREGU!RED Z^NIN3 FIELDw CH CK 9v t GATE 3-60-OS(-" ' 75I el-7/AL F.B�?d�P'ir L :r<< :TNH:)IN L-inN-! Ft :l.1 ghgt-TI-MW November 5, 1998 Mr. Orlando Corsi 114 Glencrest Drive North Andover,MA 01845 Re: Sewer Hook-up and Betterment Fee Dear Mr. Corsi: Please be advised that our sewer consultant, Guertin Associates, has determined that your sewer connection should be part of a future sewer project, specifically Phase 3D, and not part of the current project, Phase3B. This decision is based on the location of your septic tank outlet,which is to the right side of the house as viewed from the street. A sewer connection to the sewer in Phase 3D would be shorter, less expensive, and have better pitch than the connection to the phase 3B sewer. We expect the Phase 3D sewer to be installed in 3 or 4 years. In the meantime, you still have the option of connecting to the Phase 3B sewer if your septic system fails. This Division concurs with Guertin Associates regarding the location of your sewer connection, and therefore the connection requirement from the Board of Health should be lifted. Likewise, your residence will be assessed a betterment fee under the future Phase 3D Project, not the current Phase 3B Project. If you have any further questions please contact this office. Very truly yours, Timothy J. Willett Staff Engineer CC: Bill Hmurciak,DPW Director Jim Rand,Director of Engineering,DPW ! Sandy Starr,Health Agent Ben Fehan, Guertin Associates o Town ndover No. o66 / C( of�Q COCH1 I Q�- dover, Mass., 1Ew 0'?IITED P?a BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System � BUILDING INSPECTOR THISCERTIFIES TNAT.... .. .. .�..0................�..�.g......................................................................... A l Foundation has permission to erect../'!. ........................... uildings on ......I..I. ....�� lV.11I / �7....... Ip.�............. Rough to he occupied MO y ��p d as........... 0..........44......kil............A.f!....... . n . .. �. . .. Chimney provided that the person accepting this permit shall in every respect cm to the terms of ttie 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 RqqC *0 PER-MIT EXPIRES AIN 6 MONTHS A S Final 130101 UNLESS CONTS T�-� RUC.--�T N ,�T R.T -, ELECTRICAL INSPECTOR � 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. SEE REVERSE SIDE Smoke Det. 3 910 Date....... �aORTM TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU j This certifies that .....,D..'1— has permission to perform .....J—..!�.......�A�1 f wiring in the building of.......C C).f2. .......................................................... at.....f//�.�..�r...'`LPA►.G.l�/�P�,t��..?..✓�............... .N rth Andover, Fee..M,!�... Lic.Noi!. �a.,.l�.................. CTRICAL IN E R Check # I 3 910 /' �� d� Date........(..��. ....... ./.. 1 r40RT1� 3re'����'�"�1��0� TOWN OF NORTH ANDOVER PERMIT FOR WIRING. �S3 CMUS This certifies that ..... .... .......... has permission to perform ...... C wiring in the building of.......CC)./Z. .I.......................................................... at .// ........ ....,.t.�.....'/�............... .N rth Andover, Fee..�l�cO?... Lic.Noe .Za,� .........:........ CTRICALIN E OR Check # Staple eldelS IOIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII L AORTH BUILDING PERMIT OFsz,�o ,6�a r4 be p M �° O71 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION x h y'� �/ 4 xwrcwiwwc � Permit NO: !!!!!! Date Received 7 Q�gATlD �h �SSACH�1`��t Date Issued: w IMPORTANT: Applicant must complete all items on this page LOCATION / Printf PROPERTY OWNER /�/ ` 61-4 I / - Print MAP NO:�C�ARCEL: ZONING DISTRICT: Historic District y no Machine Shop Village ye no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family Addition Two or more family Industrial No. of units: Commercial Repa cemen Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands_ Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identific ion Please Type or Print Clearly) OWNER: Name: 0P L,41-1-pa C_csa� �. Phone: 9 07f;--G99"' 3 760 Address: .&9-1-H 4 CONTRACTOR Name: Phone: Address: �:3 C=149►a-D x)9-7 1 �!P S 2a. 1N1 VI- Supervisor's Construction Li"f, ? Exp. Date-:kolgsq Home Improvement Licens F 02a 1,3 Exp. Date: dZ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMITLS12.00 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Qo, koo FEE: $ Check No.: /`j Receipt IN c3� NOTE: Persons c retracting with unregistered contractors do not have acNs to the gu I•aI and Signature of Agent/Owner Signature of contrac 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 Siqnature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning 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 signature/date COMMENTS f 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 I NOTES and DATA— (For department use i I ❑ - Notified for pickup Date Doc.Building Permit Revised 2008 r 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 o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ 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 pp Permit Application ❑ Certified Surveyed Plot Plan Li Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report If Applicable L3 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 ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all 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 lication Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 i Location F No. Date ,O t • TOWN OF NORTH ANDOVER . Certificate of Occupancy $ ,.,�- Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL b$ Check#ww 25538 Building Inspector 1-lassachusetts- Department of Public Sxfch IM Board of Building; Reg lati(ms and Standards IM Construction Supervisor License r I License: CS 55341 t ANDREW E CORNELLIER III 3 CHARD RD TYNGSBORO, MA 01879 M1+ I. Expiration: 8/28/2012 i ('ununi.kion�r Tr#: 3450 i �/. ° License or registration valid for individul use only o Office of Consumer Affairs&Bdsiness Regulation g Y 4 = , HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: — _ Registration: .140298 Type: Office of Consumer Affairs and Business Regulation Expiration: 11)/1/,2013 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 A.L. ORNELLIER PROPERTY CARE&CO. ANDREW CORNELLIER 54 SAYLES ST. LOWELL,MA 01851 Undersecretary Ni7ot validout si ature NORTFHI Town of t E : ., ndover O No. *� V h ver, Mass, C OC NIC Nl WICK �d A�RgTED r'PP,`'(5 PERMI . BOARD OF HEALTH Food/Kitchen Septic System THIS CERTIFIES THAT .................. ......... 2.. ...I.. .4........... ..... .. .............................. BUILDING INSPECTOR . vh... has permission to erect ..... buildings on .. L �I�► ,� , , , , Foundation Rough to be occupied as ...... ... . 91 ..�....... ......... . ... ..... ...... .. �.r..11....... Chimney provided that the person accepting this permit shall in every respect confm to the r of the application Final on file in 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 NTH ELECTRICAL INSPECTOR �0 UNLESS CONSTRUC I ST Rough Service .............. ... ............................, ,._ .. ........... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Permit Required to Occupy Buildin�Buildinn 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. Smoke Det. SEE REVERSE SIDE � NORTH Town of t E �� ndover 0 . No. h ver, Mass, COCMIC MlWKK ��• A0R4TED P4��.�� S u BOARD OF HEALTH Food/Kitchen PERM Septic System L D• THIS CERTIFIES THAT I BUILDING INSPECTOR . ... .... .... ::... Foundation has permission to erect.......................... buildings on .. LA.. .. . . ....�.... Rough to be occupied as ......W.14416)....... ......... ... ..... ...... ..~ 'of' .�..4 ..... Chimney provided that the person accepting this permit shall in every respect conr to the rms of the application Final on file in 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 NTH ELECTRICAL INSPECTOR UNLESS CONSTRUC I ST Rough Service ............... ... .. ........... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE AL. CORNELLIER Property Care & Construction Co. 3 Chard Road Tyngsboro, Ma 01879 978-490-7716 AL.Corn@comcast.net Construction Supervisors License#055341 / Home Improvement Contractor Reg#140298 Proposal Submitted To: Date: July 3,2012 Corsi Residence Job Name: Home Renovation 114 Glencrest Drive North Andover, Ma "Revised 7/10/12 6:45PM" ATTN: Orlando Cell 617-828-7695 As discussed,we hereby propose to do the following installations & renovations to the home at 114 Glencrest Drive in North Andover Ma. Project 1. Miscellaneous Scope: - Provide and install temporary supports at front and rear entry roofs Remove and dispose of existing columns, post and handrail system Furnish & install four(4) new PermaCast fiberglass one (1)piece load bearing smooth tapered columns with Tuscan base and cap. Match diameter of existing columns. - Furnish and install (8) new Azek post sleeves with 5 inch island caps and base skirts Furnish and install Azek Premier top and bottom rail system with square balusters - `for front& rear porches" Apply one (1) coat of exterior oil primer and two (2) coats white semi gloss exterior oil paint to fiberglass columns - Replace two (2) 1 x 6 corner boards at the front entry with Azek Replace one(1) 1 x 6 facia board to the left of the rear entry with azek Conduct repairs to rotted patio door jam using 2 part wood epoxy (paint repaired areas as needed) Replace rotted bottom rail along rear deck with lx 6 azek A /1 • Align front gutter • Repair door bell • Remove damaged plywood roof sheathing on shed and replace with CDX plywood to match—"replace damaged metal drip edge" • Install owner furnished roof shingles at the shed • Replace damaged facia,corner boards and trim on the shed with Azek • "Drill drainage holes at corner of back deck" Continued Project 2.Window Scope: • Remove and dispose of the existing window and exterior trim • Install owner supplied Pella windows and interior trim • Use caulking and Grace window rap during installation • Furnish and install Azek exterior trim using exterior finish nails & Cortex fastener system • Apply insulation where applicable • Re-install existing interior window trim and fill nail holes • Apply stain & polyurethane as needed ** Note: Stain match to be made as close as possible at Lynch Paint in Westford Ma. An exact match can be difficult where existing trim has aged and the window jam is a different species (white pine). Project 3.Rear Deck/Miscellaneous Repairs Scope: • Remove and dispose of existing rail system at rear deck • Provide and install eight (9) Azek post sleeves with 5 inch island caps—"& skirts" • Provide and install Azek Premier top & bottom rail with square balusters • Provide and install Azek trim under the existing dining room French door threshold • "Replace four(4) corner trim boards flanking large window" • Prep existing oak threshold at front entry door and apply two (2) coats exterior grade semi- gloss varnish • Adjust the existing front entry door hardware and "rear entry door" • Remove the rotted wood at the front entry crown molding and install 2 part wood epoxy. Apply one (1) coat exterior oil primer and one (1) coat white exterior semi—gloss oil finish to the repaired and existing crown molding **Note At the rear deck adjacent to the French Doors the rail posts shall be checked for strength & integrity and will be replaced as needed at a rated not to exceed 35.00/ per man hour to be an additional project cost to be documented in the project addendum." All installed Azek trim on windows/corners boards and risers under French Door if needed will be painted one(1) coat latex primer& (2) coats exterior latex white semi gloss for a sum of 940.00 and will be an additional cost documented in the project addendum. We Propose herby to furnish the labor& materials for the above as listed below. Project 1: Labor /Material 10,059.00 (Owner to provide roof shingles) Project 2: Labor /Material 3,339.00 (Owner to provide window) Project 3: Labor /Material 4,404 00 Project Total $ 17,802.00 Project Labor& Material 17,802.00 Permit N/A Dumpster N/A Total Proposal $17,802.00 *X Project schedule: start the week of July 23'd/end no later than August 15m 2012 "All construction debris removed from site&project to be kept clean daily "Invoices to be submitted at project completion Note: Exclusions/Items not included in this proposal at this time: • Unforeseen condition with regard to rotted wood • Unforeseen conditions with regard to mold & mildew • Mil 1 work required for new 9 window stool � F • Possible mill work for interior arched window trim • Interior paint • Permits • Electrical/Plumbing • Any work not specified above Note—all home improvement contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza,Suite 5170 Boston,Ma 021.16 Phone(617)973-8700 ONE THIRD(113)OF PROJECTS TOTAL IS REQUIRED AT THE START WITH THE BALANCE DUE UPON PROJECT COMPLETION. All material is guaranteed to be as specified for the term of one year. All work to be completed in a workmanlike manner according to standard practices. Any alterations or deviation from the above specifications involving extra cost will be executed only upon written orders to be documented in the contract addendum,and will become an extra charge over and above the estimate at a rate not to exceed$70.00/hr All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insur Authorized Signature: Acceptance Of Proposal—the above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified and execute any related permits. Payments will be made as outlined above. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Signa re Signature g ure Date of Acceptance KAZANJIAN ' S C 0 N- TTAINER SERVICE — ROLL 0 F F S P EC I A L_ I * 10 — 40 yards * 1)erinanent or Temporary i* 111CIUSLI'lal, Commercial, Residential • Prompt, Courteous, Reliable Service Dumpster Yards 10 15 4 Wet�ht1 .5 tons 1 2 tolls 3 tolls ► - P 5350.00 5375.00 $'_5 2:5.00 Fast Reliable Service Da v Service 4 cries beyond-10cal arca is May 111CLIF all �t( depend-inv- on delivery �uea CALL FOR A FREE ESTIMATE ter" (978) 452-0265 ���-�, ������ (800). 713-9"2 i I Remove thi7finai n;SAVE for futurereference ration NFRCE 7 H"�C' Fixed —=== National Fenestration Rating Council(& Argon CPD: PEL—N-1 ENEMY PERF RMAN E ATINGS U—Factor Solar Heat Gain Coefficient 0.29 1 .65 0.27 U.S./l—P Metric/SI ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0.50 - Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole product performance.NFRC ratings are determined fora fixed set of environmental condition and a specific product size.NFRC does not recommend arty products and does not warrant the suitability of any product for any specific use.For more information,call(641)621-3114 or visit the Pella web site at www. OIla.com or visit the NFRC web site at www.nfre.o W'm1 load Design Pressure (DP)lost) . + 501- 50 In A1150 States Per ASTM E330 Canada Performance Classification CAN/CSA A440—00 FIX Air Leakage e5 Water Leakage C5 Wind Resist. C50 (Performance Grade 50) Tested to AcNSI/AAMA/NWDA 101/I.S.2-97 .wdme�comrma 1 F-050 6Ox75 WDMA License Number:411—H-1140 Tested to AAMA/WDMA/CSA 101/I.8.2/A440-05 M1fanulacturer Stl ulates CaM—ance tc the IicaEle standards FW-0501524x1905 WDMA Hallmark Certification. Pella products labeled with the Window & Door anu ac urers ssoCla Ion A) Hallmark Certification are tested in accordance with applicable WDMA performance standards, which requires products be tested lot sir infiltration, water infiltration, and structural performance. Peformance of Pella products will change over lime depending upon the conditions of use. For details on Hallmark Certification, go to www.wdma.com. Flonda Product Approval System(FPAS)Number FL11277.e Glazing thickness designed per ASTM E1300—3mm Window or Door Actual Size:24"wide by 23.53935"tall Meets or exceeds M.E.C..C.E.C.,8 I.E.C.C. Air Infiltration Requirements 185MCCO75—010:PELLA—SD5-070212—ASCCMFX131—024A023JWHT-5218 . R CERTIFICATE OF LIABILITY INSURANCE D IDD/YYYY) 1`- �� 7//11/11/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maria Nixon NAME: Strategic Resource Group PHONE 1AIQ No (781)246-9002 NX No):(781)246-9007 27 Water Street, Suite 107 E-MAIL s :mnixon@strategicresoureegroup.net INSURERS AFFORDING COVERAGE NAIC# Wakefield MA 01880 INSURERA:Travelers INSURED INSURER B: Cornellier, Andrew DBA: A.L. Cornellier INSURER C: Property Care & Construction Co. INSURER D: 3 Chard Road INSURER E: Tyngsboro MA 01879 INSURER F: COVERAGES CERTIFICATE NUMBER-CL11111500237 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE. INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE L B POLICY NUMBER MMIDDY EFF MPOL/DpY� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE ❑X OCCUR 6808A712460 0./29/2011 0/29/2012 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY F1 PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acadent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccitlent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY _iTORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N o Follow Directly from E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) Company E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orlando Corsi ACCORDANCE WITH THE POLICY PROVISIONS. 114 Glenncrest Rd. AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Jody Crowther/MAN ACORD 25.{2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(9ninns)ni Tho Arinpin namo onrl Innn mro ranic4orori marka of ArnRr1 RightFax C1-1 7/12/2012 4: 18: 10 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDhYYY) IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA H R. TH CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: STRATEGIC RESOURCE GROUP PHONEFAX 27 WAT R ST STE 107 (AIC,E-MAIL EJR): PRODUCER WAKEFIELD,MA 01880 CUSTOMER D#.. 77YDL INSURER(S)AFFORDING COVERAGE NAIC A INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY CORNELLIER,ANDY DBA A L CORNEI.?ER PROPERTY CARE INSURER B: INSURER C: INSURER D: 3 CHARD ROAD INSURER E. TYNGSBORO,MA 01879 INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. ;15 TO CERTIFY THAT UR LISTED BELOW HAVE BEEN ISSUED TO THE INSUM HAMM ABOVE FOR THE POLICY NOTYJRNN! HSTANDG ANY REQUIREMENT.TEROR CONOmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLJCIES DESCR13M HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICES LNfrS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMS NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (M RMYYYY) (MMODIYYYY) LMfTS GENERAL LIABILITY ;ACH OCCURRENCE 3 rGEITL MMERCIAL GENERAL LIABILITY AMAGETORENTED S CLAIMS MADE M OCCUR REMISES(Ea occurrence) ED EXP(Arty one person) S ERSONAL&ADV INJURY S GREGATE LIMIT APPLIES PER _NEKALAGGREGATE S LICY a PROJECT a LOC OCUCTS-COMP/OP AGO S AUTOMOBILE LIABILITY OMBINED SINGLE $ ANY AUTO IMIT(Ea accident) ALL OWNED AUTOS 30DILY IN..URY $ SCHEDULE AUTOS Per person) HIRED AUTOS 30DILY INJURY $ NON-OWNEC AUTOS Per accident) FROPERIYDAMAGE S r accident) I MBRELLALIAR OCCUR ACH OCCURRENCE $ XCESS UAB CLAIMS-MADE GGREGATE $ EDUC`+1131.F S E-FNT:ON S $ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY YM UB-4617P873-12 04/26/2012 04/26/2013 LIMITS ANY PROPERITORPARTNERIEXECUrNE E L EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXC.JOEC� (MmdetoryInNN) E.L.DISEASE-EA EMPLOYEE S 100,000 If yes,deumbe under DESCRPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONS/VB*CLES/RESTRICTiONSJSPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE, THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE.FOR CORNELLIER,ANDY CERTIFICATE HOLDER CANCELLATION ORLA'N`DO CORSI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 15 GLENNCREST RD BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL DEL IN ACCORDANCE WITH THE POLICY PROV AUTHORIZED REPRESENTATIVE NORTH ANDOVER,MA 01845 ACOR (2009(09) 1986-2009 ACORD CORPORATION.- h f TIMerved. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A 9j� j f-(t✓ Address: Qvraj-�o City/State/Zip:!' Phone#: Are ypu an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.F1 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. n " Insurance Company Name: AA r 1� J.(�te,0 e4q-A p JW% pP�-J,►� Policy#or Self-ins.Lie. t]Q� �- Expiration Date: Z4> e l 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. Ido hereby certifyunder th &* and�penalties of perjury that the information provided above is true and correct. 1Z 27 Signature: Date: 2/—z Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment.be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone riumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to 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 Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www,mass.gov/dia