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Miscellaneous - 114 VEST WAY 4/30/2018 (2)
Date.. 7!.!d!'.z ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .............. � '�ie .. !4-� .......... " has permission for gas installation .. ��a x!� ..... in the buildings of ......... 0. ;5 v ........................ at ..../.��. �?� ............ North A/ndover.,,Mass. Fee. �Pf Lic. No.. 0 V.. �... . .. . GAS INSPECTO� Check # & M • i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE APRIL 12 2012 PERMIT # ut, JOBSITE ADDRESS 114 VEST WAY OWNER'S NAME I HEATHER URSU GOWNER ADDRESS HEATHER URSU TE 978-208-7779 FAX TYPE OR OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIALO PRINT CLEARLY NEW:® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER - DRYER _. _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER - ROOM 1 SPACE HEATER ROOF TOP UNIT - TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I RUN A NEW UNDERGROUND GAS LINE REPLACING THE EXSTING GAS LINE INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ® BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' h all Pertinent ro 'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I ROBERT WHITE LICENSE # DZ SIGNATURE MPI MGF ❑ JP ❑ JGF ❑ LPGI (�] CORPORATION ❑# PARTNERSHIPO# LLC ❑#® COMPANY NAME:EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY I DANVERS STATE MA ZIP 01923TEL 800-322-6628 FAX CELL EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investig, ations I Congress Street, Suite 100 Boston, MA 02114-2017 Pf:in':t;F:orm V www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Imfe a -tion Please Print Legibly Name (Business/Orsanization/Individual): EASTERN PROPANE & OIL Address: ' 131 WATER STREET City/State/Zi>7: DANVERS, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate bog: 1.7 I am a employer with 45 4. E]I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.7 Roof repairs 13. ✓❑ Other GAS FITTING *Any applicant that checks box 91 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. Insurance Company Name• LIBERTY MUTUAL INSURANCE COMPANY Policy # or Self -ins. Lic. #: W C7-641-435806-052 Expiration Date: 03 / 15 / 2013 Job Site Address: I i H V PS+ a City/State/Zip:1nn, +t, A,,c l ove-, 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 herebv certify under the pains and penalties,f perjury that the information provided above is true and correct. 03/13/2013 Phone #- 978-750-6500 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. Buildinb-Depa-r-tment- 3:-City/T-own-Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 'Contact Person: Phone #: .� . .� � �� _ � � ^ � { | � a 4 � y0L. e Bin Red -&-ar - i - �= M5AR720G Process Customer Inquiries (1 2028808) 4 ■ ~HARE File f Help I About Program O Bill To Information ❑+ QA Bill To Address Company: [El1 2028808 HEATHER URSU jild URSU 114 VEST WAY fir: �+ r s g N ANDOVER MA 01845 Phone Work Fax 978 208-7779 1� II Division Credit Rating Group Type E771 4REFX [--I 16 EM Information Equipment Type r--� Ship To Information Ship To Address Company: 2028808 1 HEATHER URSU MIKE URSU 114 VEST WAY N ANDOVER MA 01845-0000 Fax Work Phone 978-208-7779 Zone Delv. Stop # On Call ID Group Type 57850 E= 16 Reference Unit # --- Mermanent Notes - - Date User Contact/information 6/23/2008 PATTIO TANK RENTAL NOTE ON FILE R 150.00 YEARLY TNK RENTAL APPLIES. WAIVE 1ST YEAR PER GEORGE 09:24 AR USER ID: PATTIO DATE: 09/17/2008 TIME: 10:13:22 called For inspection of u.g_ CREDIT INFO IPS FOR THIS ACCOUNT IS 2029614 4/17/2012 10:25 CDL Last Note/Lredrt IntormationJUunnmg tAueue Record Type Type Date Time MOD/COL User/REQ Contact/Information NOTE ON FILE R 12 09:24 AR DHOWE called For inspection of u.g_ CREDIT INFO DL 4/17/2012 10:25 CDL COL 15T DUNN LETTER 1ST 4/1712012 10:25 SHERRY FRIENDLY REMINDER Record Type Type Date Time MOD/COL User/REQ Contact/Information NOTE ON FILE R 4117120 Exit O� Start a [ " MSMENUG - PAMS Mas, ,.1 AR702G - Look Up Cus,., I AR -720G - Process C .. Inbox -Microsoft Outl.,, r�, lob Edit - Windows Int.,. I « ®� 4;11 PM Thursday, Apr 19, 2012 04:11 PM Date..A.... ,eq........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that _..................... has permission to perform .... ..u.: ...'.... ... ........ wrong in the building of ....:..........:.:..�-..................................................... at ....%/�/.........�'......................... . North Andover, Mass. Fee. �!� . "-' ....... Lic. No:3u"................ 4 ELECTRICAL INSPE Check # _. �UJJ /• r �-� Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS kvtto/ Official Use Only Permit No. �.3- j Occupancy and Fee Checkedp [Rev. 1/071 (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 PRWflV INK OR TYPE ALL INFORMATION) Date:6 -� 7— Q City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned give notice s or her inte ion to perform the electrical work described below. Location (Street & Number) , Owner or Tenanty� j Tyzz AYJ Telephone No. aG Owner's Address, WZ Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service42�ZL Amps 40:/�olts Overhead ❑ Undgrd No. of Meters-7— New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and. Ampacity Location and Nature of Proposed Electrical Work: completion o the followin table may be waived bY the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA o. of Luminaires Swimming Pool Above E:;] In- 0,o. o mergency ig g d• grnd. R!!IeM Units No. of Receptacle Outlet No, of Oil B»rn ers�""res" p.LARi�S No of ,:ones 1 No. of Gas Burners No. of Detection and Initiatin Devices t No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained Totals: _.._._..._....._.._..._. _. _._. _._. Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW Municipal Local ❑ Connection ❑ Other No. of Dryers Heating Appliances KW Security Systems:* No. of Waterof No, of Devices or E ----valent Heaters . KW No. of No Si s Ballasts . Data Whin • No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: CO Attach additional detail if desired, or as required by the Inspector of Wires. ' Estimated Value of Electrical Work: kv (When required by municipal policy.) Work to Stark Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify) I certify, under the ains and p n . s of perjury, that the information on this application is true and complete - LIC. NAME- A J�%f/�j �i�e _ LIC. NO.: Licensee- Signature �� '�j9j �/ LIC. NO.: 5�, (If appli le, enter exempt " in the license number line) Address: Bus. Tel. No. <5A L46_411a1 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. L lc. 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 Signature Telephone No. PERMIT FEE. $ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t j www.mass gov/dia . WorkeW Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: . Pbu an employer? Check the appropriate box: I am a employer with 4. ❑ I am a general contractor and I VL�rtployees (full and/or part-time).* f I am a.sole proprietor or partner. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.) 3. ❑ I am a homeowner doing all work myself. [No -workers' comp. insurance required.] t .A. have hired the sub -contractors listed on the attached sheet. t These suit -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4),and we have no employees. [No workers' comp. insurance required.] r Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. Q Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑.Other -rr--- ••p, wjG &b ooz" 1 must also nit 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 sheat shownrg t«e name of the sub -contractors and their workers' temp. policy information. 1 am an employer that is providing:workers' compensation irp r cefor ncy employees. Below is the policy and job site information. z A Insurance Company Policy # or Self -iris. Lie. #:` Expiration Date: Job Site Address: City/State/Zip.A 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 e. 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 I or insurance coverage verification. ! do penalties of perjury that the information provided above is true and correct OffJcW 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 -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial Accidents for confnmation 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 nurnberlisted below. Self-insured companies should enter their self insLuar16e 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 lnvestigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigatlzons 600 Washington Street Boston, MA 62111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/di.a ` Date. .. �.. 'h TOWN OF NORTH ANDOVER PERMIT FOR PLUMBi'NAP3 ,SSACMUS� Q f This certifies that . !..��.'` ci.� . f . • ...... . ' • • • • ..... . r has permission to perform ..,,�!?����'�... ���'"`' ? -• plumbing in the buildings of . !.... ..�... .. `.. I ............ • . �/W %-..I-V fjc ................ North Andover, Mass. Fee. ... Lic. No...V..... �.��.�.................. . . PLUMBING INSPECTOR Check # 80u2 �ff' S MASo� t3 MASSACHUSETTS UNIFORM APPLICATI N FOR PERMIT TO DO GASFITTING (Print or Type) N, % xN 1 >OuE /Z ,Mass. Date Permit # Building Location VES TWO Owner's Name /74 %(. jp�'S Owner Tei# 477 741 Type of Occupancy New ❑ Renovation 0R-epIacement ❑ Pian Submitted: Yes ❑ No FIXTURES Installing Company Name /"'�%1�1 /9- G-kS t TN Address/ 110 S, AlAi/V S-77 Business Telephone # Z d 3U � 36 o-% Name of Licensed Plumber or Gas Fitter /,<-16� V Check one: Certificate ❑ Corporation ❑ Partnership n'Firm/Co. INSURANCE COVERAGE: I have a current amity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes p� No ❑ If you have checked ygs, please indicate the type coverage by checking the appropriate box. ei A liability insurance policy [T Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent i nereoy cerury mat au of me aetaus ana mtormanon r nave suomrttea for emerea) in aoove app ucauon are true rate to the oest c knowledge and that all plumbing work and installations performed under the permit iss d fo his application w' I be in mpliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of therat La s. By Type of License: 70 , -Plumber Sig re o icensed Plumber or Gas Fitter Title • -Gas fitter • -Master License Number Cityfrown Journeyman APPROVED (OFFICE USE ONLY) my • • .%.4` N1aS*aCI1u.ctt% - Department of Puhiic Safrt% Board of Buildinu, Re-uttlation% and Standards Construction Supervisor Specialty License License: CS SL 100997 Restricted to: RF,WS,SF,DM REEVAN PARMA 14 WAYNE ROAD PEABODY, MA 01960 �—� - Expiration: 6/5/2012 t „irmriw„e�cr Tr:: 100997 71. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 160945 Expiration; 9/15/2010 Tr# 274725 Type: individual REEVIE PARMA REEVIE PARMA 14 WAYNE RD. PEABODY, MA 01960 Administrator Commorn.vealth of Massachusetts Division cf Registration Board of Plumbing Exam" REEVAN M RMAi --- 14 WAYNE RD- € 1_. -1- -174 1PEABODY. PEABODY. Journeymanasfai#e`-::: GF5053-J 05/01 2010 00301 2 License No. Expiration Date. Serial No. .%.4` N1aS*aCI1u.ctt% - Department of Puhiic Safrt% Board of Buildinu, Re-uttlation% and Standards Construction Supervisor Specialty License License: CS SL 100997 Restricted to: RF,WS,SF,DM REEVAN PARMA 14 WAYNE ROAD PEABODY, MA 01960 �—� - Expiration: 6/5/2012 t „irmriw„e�cr Tr:: 100997 71. Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 160945 Expiration; 9/15/2010 Tr# 274725 Type: individual REEVIE PARMA REEVIE PARMA 14 WAYNE RD. PEABODY, MA 01960 Administrator ACORQ CERTIFICATE OF LIABILITY INSURANCE 0ii06/2 0 ' PRODUCER (978)922-2288 FAX (978)922-2731 Appleby & Wyman Insurance Agency Inc. 152 Conant St. Beverly, MA 01915 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED N E F P INC 140 SOM MAIN ST MIDDLETON, MA 01949 INSURER A: National Grange Insurance Co. 14788 INSURER B: INSURER C: INSURER D: INSURER E: ( nVFRAr.FC 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS Proof of Insurance GENERAL LIABILITY BPO96943 01/05/2009 01/05/2010 EACH OCCURRENCE $ 1�000� COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50, CLAIMS MADE ❑ OCCUR MED EXP (Any one person) $ 5 A PERSONAL & ADV INJURY $ 1 0� GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Z,M,ON POLICY jE d LOC AUTOMOBILE LIABILITY ANY AUTO 11119096943 01/10/2009 01/10/2010 COMBINED SINGLE LIMIT (Ea accident)$ 1,000, BODILY INJURY (Per person) $ A ALL OWNED AUTOS X SCHEDULED AUTOS X HIREDAUTOS X NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY 0UMS43 01/05/2009 01/05/2010 EACH OCCURRENCE $ 1,000, OCCUR F1 CLAIMS MADE AGGREGATE $ 1,000, $ A $ HDEDUCTIBLE X RETENTION $ 10, $ WORKERS COMPENSATION AND W1096943 01/05/2009 01/05/2010 TH- WCSTATU- OrR A EMPLOYERS' LIABILITY ANY PROPRIETORIP_ARTNER/EXECUTNE E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,00 OFFICER/MEMBER EXCLUDED! yes, describe under SPECIAL PROVISIONS below S E.L. DISEASE • POLICY LIMIT $ 500 00 � OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS ttI=RTIRIRATF i4ni nj:R ' CANCELIATIAN ACORD 25 (2001/08) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial -version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Proof of Insurance Marc Slats /CBESCI ACORD 25 (2001/08) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial -version www.pdffactory.com �j- O. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 01/08/2009 PRODUCER (978)922-2288 FAX (978)922-2731 Appleby it Wyman IESErance Agency Inc. 152 coaant St. Beverly, MA 01915 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIL # INSURED lievie Parra DBA: C/O NEFP 140 S Main Street Middleton, MA 01949 INSURERA: National Grange IESUranCe Co. 14788 INSURER B: INSURER C: INSURER D: INSURER E: CAVFRAr:FS 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MSR DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TYPE OF INSURANCE POLICY NUMBER EFFECTNE POLICY EXPIRATION LIMITS Proof of IEsnrance GENERAL LIABILITY TBA 01/01/2009 01/01/2010 EACH OCCURRENCE $ j 000, X1 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 5500 CLAIMS MADE ® OCCUR MED EXP (Any one person) $ j0 Aff— PERSONAL & ADV INJURY $ 1,000'"A GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPUES PER: PRODUCTS - COMP/OP AGG $ f, 000 POLICY JEa LOC AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMB (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F] CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND TH- WC STATU I FR EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT b E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? H yes, describe under SPECIAL PRWSIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CFRTIPIrATF HAI IIFR CANCELLATION ACORD 25 (2001108) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Proof of IEsnrance Marc Slafs /CBESCI ACORD 25 (2001108) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial version www.pdffactory.com Location No. TOWN OF NORTH ANDOVER i ' Certificate of Occupancy $ s' •'�� Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee TOTAL Check # 15513 Building Inspector TOWN OF NORTH ANDOVER JAL JL Lun Z - rKUrhKI Y UWf4EKSMF/AU'1't10K1LED AGENT BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ATE F77 1.3 Zoning Information: Zoning District Proposed Use T'I45 M U R PtjY Name (Print) SIGNATURE: 1.6 BUILDING SETBACKS ft Building Commissioner/I for ofStildings Date Front Yard 1 3ca. JL.LMI i- 3 1114r%JAIV AILU11% t 1.1 Property Address: IN VES 7- 1A JAL JL Lun Z - rKUrhKI Y UWf4EKSMF/AU'1't10K1LED AGENT 1.2 Assessors Map and Parcel Number: ✓ %�� 2, Map Number Parcel Number 2.1 Owner of Record 1.3 Zoning Information: Zoning District Proposed Use T'I45 M U R PtjY Name (Print) 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RecjWred Provide Reqdred Provided Required Provided 2.2 Owner of Record: 1.7 Water Supply UCLI-C.40. 54) Public ❑ Private p 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 2 O b h z M O anr z Q JAL JL Lun Z - rKUrhKI Y UWf4EKSMF/AU'1't10K1LED AGENT 2.1 Owner of Record T'I45 M U R PtjY Name (Print) 1t VE5 7- k),4 y, Nb>"?j Address for Service : Tr b3 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: o S UTTD A S T. AP M." 2 o VR, 11h License Number Address Signature Telephone Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name �, n +,a O (.L%%bbl% S,.T, r /V 6Afj Op U E/4 M Registration Number Addresslo,212 0 9 .s L ✓� [ Expiration Date Signature Tele hone 2 O b h z M O anr z Q mi SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 & 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTIONS Description of Proposed Work check a R applicable) New Construction ❑� ,4xisting Building Repair(s) ❑ Altel'at'or#a(s)F ❑ Addition Cl Accessory Bldg. ❑ Iremolith 0 Other ❑ Specify Brief Description of Proposed Work: S %rR. 1 )9 4— R t7 Z) ` SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant x° > s1 ah t t py IIOr I . Building �Q f (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total.Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 3 4 Mechanical (HVAC) 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION DAV 1, AV l C As _T_,K d ALE as Owner uthorized Agen of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief C Print e Signature of 0wrter/A ent NO. OF STORIES Date SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 s1r2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOJING X MATERIAL OF CHRvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4 DAVID CASTRICONE ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 7 HILLSIDE ROAD, BOXFORD, MA 01921 In North Andover 978-683-3420 In Boxford 978-887-6147 In HaverlsN 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises below described: ..1411.,''. ti' C3 Owner's Name .......... ...CL.rZti.......��..........................................................Telephone#.....�.�:3...�l....�................ /... V$. , tIl Job Address...., �.... ....�� .. ............................... City..�cr.....��4.�.�"...................... State...1�[.17.............. Specifications: ...................................................................................................................................................................................................................... Strip existing shingles. IvApply new drip edge to all ...................................................................................................................................................................................................................... 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. 1/Apply felt paper underlayment. install ridge vent to cc •�l P; �� ............... I ........ ................ ............................ ...................................................................................................... .� Reroof usingshingles with a ... ...Q... �p...................'. year warranty................................... ✓ Counterflash chimney. /New vent pipe flashing. Legal disposal of all debris. ...............................................................4...............�i...................................... ............................................................................................. Area(s) to be worked on: ................................. 4.............t.4�..... ..tt` ..rir..f................................................................................................................. ..................................... I ......... . ............... . ...........................:.......... .Lc� �l"- ..... ` '................................................................................................:.................. . ................... One Year Workmanship Warranty (Not Transferable) Manufacturer's Warranty as specified by manufacturer 6�..�. Materials and Labor to cost $.... S..f 6" D ................... Payable .Jd�:.f'.............. on .....� l..�: "........ Payable .......... :.-':'............ on .................................. Balance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job 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, water stains when roofing shingles have not had adequate time to cure). 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 owner(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. 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, nor any agreements collateral hereto, not 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 shall be excluded from access to the Guarantee Fund. Approximate starting date of work..................................................................... Completion date .............................................................. Receipt of a copy of this contract is hereby acknowledged, and it is f i ther acknowledged by the undersigned that the foregoing .�\ � ��,• G r:arun•iur„�rrr'/� r� , /�r...,r,vrr...r((' Bnard of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 104569 Expirz.ion: 7/14/02 Type: PRIVATE CORPORATION DAVID CASTRICONE ROOFING, 3 MaP 05astricone 7 Hillside Road Boxford, MA 0192' -- Admin:stratur • Town of North Andover * tAORTH O �t�to ,6 4• e O Building Department o 27 Charles Street North Andover Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 o� "`~ �• ^-, rEo ITS US DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: I Facility location 4 Signature of Applicant s'/ 2 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. .1 d • ua � u o w° c u a cn O as co -d � w° x neo a x U w Oa a a _C o w w" a v w w o u: v) c w z f° w w w cA z 41 cn v v o cn E V CL N t h i ti C O A ca CO C: Of C .fl m O cm c c N CD L O Z 0 0 mq", O 4.4 "-a 2 O Qi i O 0 0 _IO 0 0 03 CD � R � 0 � O cc 0 d a- cm Q CD cc v J •0 .Q 0 � C ca Z42 CL � V y R C C • C _R C. CO) C) CD Ir w irw U) c. c CD o � C N O C ' � O v V QC W R cc 3 o� N Ea CD 'r 0 C1 "Z V o c. N EE :�o m c� C,3' 0 .r os CL= m m N ©3 c m� C C � � � m � tL C y W NJ E a� ca m> = O 'O _ CM -6 O Q �. dCt C3 CO) [7 Z O O CL a H 0 ,mc = m CD A3 H ti m Ly �0+ Cc CD r-• � O !O �CSZLU H L y �Ev C H m ED O m C3 ;C C Coo CS m .5 0:5 H = _c t 0 CZ 0..r m E V CL N t h i ti C O A ca CO C: Of C .fl m O cm c c N CD L O Z 0 0 mq", O 4.4 "-a 2 O Qi i O 0 0 _IO 0 0 03 CD � R � 0 � O cc 0 d a- cm Q CD cc v J •0 .Q 0 � C ca Z42 CL � V y R C C • C _R C. CO) C) CD Ir w irw U) Location /�V& 17— W4 No. / Y/ Date IPADtl Check # J 4115 175;8 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ / 0?U. Cw Building Inspector TOWN OF NORTH ANDOVER WELDING DEPARTMENT AFPL1CATlONTOooNslRtrcrREFA %RRNOVAM OR DEMOU M AONEORTWOFAMILYDWFJNC BURRING PERMIT NUMBER: / DA'T'E ISSUED: Q � �Z-0 SIGNATURE: BuddingComariss;arler r of Buftm Date SECTION 1 -SM INFORMATION 1.1 Property Addr= IOU 1.2 Assessors Map and Ps od Number': I b `i 'D Map Number Pared Number 1.3 Zaneglat'am>stim: zc& Diatb! amused Use 1.4 RgwtyDimeesim , L tAter 1.6 WUDING SETBACKS(ft)- - Front Yard Side Yard - Rea Yald Reppled Provide Provided RqWredProvided t.T tlet s yM.ULG4a. ser) is I7eodT�eLlomogiots — _ Ll Sew-VDxpwdS3M- .7Wa MUM o 20ei o.miaertaadUp a o onskokpoea sy WW a POWSECTION 2 - PROPERTY OWNERSWIAUTBORUMD AGE" 2.1 Owner of Record 01631 1tna ��ICCTId� �J� UQS Nemo (Print) Address for Smviee : �► 3-c�yl� Signature Telephone 22 Owner of Road: Name Peart Address for Smvice: Signature MOM SECTION 3 - CONMUCIION SERVICES 3.1 Licensed Constraclion Supmvisor: ConsuucbonS pmvisor. 31 ►-T�YJ«�%� RV L . v -t ►Q�� IC)► I i_�� ©1�a Addrm Siganturo Tdephare L�La -Soon Na Applicable ❑ LiceaseNamber 61 olp 32 Registered Hie impmVeakat Ctmtracta s tiompaayNeme ` ' 4"� Not Applicable ❑ Ragiwa Nsmber h ld I it 1� �>> 'em ` \—. /-¢ S' acme LaSAEM 4 -WORKERS Workers Compensation lnsumace affidavit mast be oompleted and submitted wild this application Faihae to provide this affidavit will result in the do w of the issuance of the buift Signed affidavit Attached Yes .......0 No ...... n sicnoN S Description ProWork t New Construdion 0 Exist q Building 0 Repait(s) Alterado*s) 0 Addition 0 Amy Bldg, 0 Demolition 0 other 0 SpM* Brief Description of Proposed Work: Item - - Estimated Cost (Dollar) to be C eied it licaat t 1. Building / ©D, (a) Building Permit Fee Muftiplier 4 -WORKERS Workers Compensation lnsumace affidavit mast be oompleted and submitted wild this application Faihae to provide this affidavit will result in the do w of the issuance of the buift Signed affidavit Attached Yes .......0 No ...... n sicnoN S Description ProWork t New Construdion 0 Exist q Building 0 Repait(s) Alterado*s) 0 Addition 0 Amy Bldg, 0 Demolition 0 other 0 SpM* Brief Description of Proposed Work: Item - - Estimated Cost (Dollar) to be C eied it licaat " } ' O>E'FTG[iVSE:Q s.t° . -0 1. Building / ©D, (a) Building Permit Fee Muftiplier 2 Electrical (b) Estimated Total Cost of Conswction 3 Plumbing Building Permit fisc (a) x.(b) �� O 4 Mechanical HVAC S Fire Protection 6 Total 1+2+3+4+5 O Check Number I/ J �c I< 9. - L o u>,e r 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*********************** g LS�( ) PHONE lY� `� i �f) a AP�LIWT I`�,� _ LOCATION: Assessor's Map Number 104D J6PARCEL ,Q-7q—g'&q3 SUBDIVISIONS i ` LOT (S) STREET I N VIS- [WJ ST. NUMBER **********************************OFFICIAL USE ONLY*************** **** RECOMMENDATIONS -QF TOWN AGENTS: CONSERVATION ADMI STRATOR DATE APPROVED DATE REJECTED COMMENTS ltd S 7 foo TOWN PLANNER DATE APPROVED _ DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 Jim MORTGAGE INSPECTION BAY STATE SURVEYING ASSOCIATES INC. Mpg # 100 CUMMINGS CENTER, SUITE # 316J, BEVERLY,MA., 01915 E JI. ' ;jC TIO'r!i ,ANDq� A"NOTES: t) This Is a mortgage in an speetlan.}ury a „ ,¢ Insfrument surve , therefore IN. i 9tt A E : 6o DATE :.........:..3..............oP) d •„ mortgage inspection ur oset ri be used o �.. bllsh boundaripe RE C : z ruction of any type of ImpirdV ` .9.........�4....... _ to . ) This survey is based on sures ffIIj� Q is....... 3) Bushes, shrubs, fences and tne111tf1i{,do`( necessarily indicate property Ilrn{.'. i 4) Whenever an offset is 1' 4- or Ita ;14�two. survey b recommended to dete . i - at 'on f ie building(s) as shown, either ones, and any possibla encr6x0.bhY �) ed wi t e Ipcal zonin * setbacks at the time of � OHsats shown are approxlmat4;r� o ' used only for the determinatlon f : ir; , pt (to j ct{ori or�(s exempt fro violation enforcement y k oh unde?Mass. G.L. Title d Chapter 40A Section 7 be used to establish property 04s, Q; (''` (0) In my professional o Inion the b.�( a are not located In the special flood hazIold defined by H.U.O. MAP# REGorr..E�ND EiE✓Aira�.J skiley RETE r/NG- FLOo,7 H 97✓4/1D zz �•ti; ' ` M :rad . � I►� � C �` � C s Z , A11 1 a T\ r 16 4.t � I f a': 12.10 OA tlA- Arl I { ! Af. t .. 9*g j 14 i rr � ' •x I o SEL t ' f'�''i°�3i!Y!F?t:�i`v= w s .. e .s, c- �. �:.. ,�.rr.. �- �l9?�' AUG -6-2004 16:06 FROM:AXEL PEPIN 617-287-9460 TO:19784683002 P.2 © I am a homeowner performing all work myself. Project Type New Construction e el I am a sole proprietor and have no one working in any capacity ❑ Building Addition ❑ I am an employer providing workers' compensation for my employees working on this job company name: address: city phone #• -- .;.s:.. ❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensationpolices: company name: address city nhone #- insurance co qy CY # coma name: ad City Phone #:_ ii`n/s�urance co w o}Lcy # if1Nl�addiHou�dsli�taf;n 'l �. J-.�AJ :� «_t.a$o...,� SI,s" and/or Fafim a to txenre eo�erage ss r egauYd ander Sextion 7SA of MGL 152 can kad tb the Unposi>ton Of criminal pen one years' imprisonment as well as cion penalties is the farm of a STOP WORK ORDffit sad a fine of S100.00 a day against me. I aaderstaad that a copy or this shhment may be tomarded to We Ofiitx of Inveatigattona of the DIA for coverage verification. I do hereby certify under th ins and penaId o,/ perjury that the information provided above is true and correct. Signature Date Print name Phone # *.q. {s^c.',r "��u*�i�.;r d2A,-�::'::. �'�S: - �'?'���"+ �'vC''�—`--�-�y�w!`::rte-',+1�i.z"'�_-.?�:ss-z�iuw.-v...ai. ''..�ts.ds. .».i..:. _•,,;_.;..c.a.__ ... JP, Y Or town Official 1 ;; t.} official ase only do met write in thfs area to be completed DY eiil' . city or town: perte # �neeasid n Dep M Boareat J ' F ❑ cheek if immediate response is "Maited NA ❑Selectmen's miOffie +� ❑Health Department p ❑other ' contact perso . n• hone b; -+ tem (...d SMI. M) Board or Bonding Regulations and Standards HOME BMPROVEMENT CONTRACTOR Registration: 127346 Expiration: tON4/2004 Type: DBA DECKED OUT SCOTT ROY 31 ASBURY AVE HAMILTON, iv1A 01982 m .4— a:nEnistratax license or t+ tints Vaud for koffividul am only before the expiration dam If found return to: Board of Busking Regnlations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 Not valid without signature 40 � o � a a a a V) a v w Lz1 C7 c w w A in o cn C O _ O N C1 C.) MMJ 3 a� O A m y 4 Ea o� o a om P* r c� o ts alp aE ' O m oSo3�r C C+ C� Co C C i •O O m L ` H i 19 d �.1Clo O y m - oA 4D 0 aw m - h m �X: c�a C' yZ O A O - Co C C O C Q ` h m C �CN = m mCi�0 CO) C W O yam+ CLLI yt, •.. W .E o -0 a y CD L. H �ICo COnmm9 s Go�CD Z $ C -Z 0 IC w z 0 a z 0 U 9 N u O ,,p CD C• L CD z o, O y G C Cm O � LA O O 'E m m CD t O� O O c O L O m a Ca cv c Z C CL C.) Ca C CL C CA is w 1I0 vI /w� �I / 19 w C9 LLIw U) Date. !0 .... . TOWN OF NORTH AN PERMIT FOR GAS INSTALLATION This certifies that ...%� J�.. ` . ,/ �, ��/? °.� ....... has permission for gas installation A ' in the buildings of .,..%1 �..:.............................. . at .. IAf. - I'.: �. Fee. G Lic. No.. /.1- i.,? ... Check # 7 A441 North Andover, Mass. 'GAS INSPECTOR I� G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Building Location 114 VEST WAY Owner Tel# 978 208 7779 Date 6/16 & 6/17 2008 Permit # (o '1 L( I Owner's Name MIKE URSU Type of Occupancy RESIDENTIAL New W1 Renovation❑ Replacement FIXTURES Plan Submitted: Ye[] No❑ Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6623 Firm/Co. Name of Licensed Plumber or Gas Fitter 3—ft f 4-n INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ I No ❑ If you have c ecked rtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy✓❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I herebv certifv that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License:/,.r. • • lumber Signature of Licensed Plumber or Gas Fitter City/Town APPROVED (OFFICE USE ONLY) 9d4Gas fitter • -Master License Number • -Journeyman • J • P • • Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6623 Firm/Co. Name of Licensed Plumber or Gas Fitter 3—ft f 4-n INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ I No ❑ If you have c ecked rtes, please indicate the type coverage by checking the appropriate box. A liability insurance policy✓❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I herebv certifv that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License:/,.r. • • lumber Signature of Licensed Plumber or Gas Fitter City/Town APPROVED (OFFICE USE ONLY) 9d4Gas fitter • -Master License Number • -Journeyman