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HomeMy WebLinkAboutMiscellaneous - 120 WOODCREST DRIVE 4/30/2018N r 11 Date .....t .�.:. "6 ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that.............................................................................................................. has permission for g installation ......... :A est -� eSF .......................................... inthe buildings of ...........:... a.N.....................:.........................:................................. at ...... i.2,0..... . ........................ ./e—..., North Andover, Mass. Fee ..;. ........... Lic. No.t5ft2-........ ..................................:................................. GASINSPECTOR Check # 2_ 09926 rim'' ,IV ICU MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS F//,^,ITTING — /WORK CITY NORTH ANDOVER { MA DATE 3-20-2012 PERMIT # L ce l JOBSITE ADDRESS 120 WOODCREST DRIVE { OWNER'S NAME ANNETTE M VISCONTI { GOWNER ADDRESS SAME { TEL 978-790-7322 { FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL ✓® PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES® NOO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ^__j —j __j _J _J ^J ___J __j _ _ f __j ___j _ I .___-J .__....1 _J BOOSTER _.� e J .._.J (_ _J ___j I _ J .J _____( ___ _] _ I __j CONVERSION BURNER �.J 1 _ f , TI � _.� __j __j __I __j _.,_._J ._..__.1 ____.I _.._I _j COOK STOVE � I -,_el _. _IAA .......__J _ _ I __j .____j __j I I_ I .__j __J DIRECT VENT HEATER l __ _J E __j __J T J J I ._....,J --J —__ i __j __j ____j DRYER T I _ _J ___I __..J e«<1 �--_-1.T-1 __j .__r_j ___j ._1 ____j _-_-_j __j __j FIREPLACE ^J J ---] __J —i __,J _ I _J I __j __j --] __j --.—i ._j FRYOLATOR __J __..__J ,_J —__.J ..- _J __j __j __a __j I __j _.— I __,1..-._.__.._1 _____a __j FURNACE .J __1.-- _—_I __j __J _.-__1 II I I ^ I _j ._1 __j --_.._-1— i GENERATOR �J .-_ 1 _--Il I ---J -- J ___j _—._j --.1--i a —1 ,J _j --J GRILLE �� _ I __j __j __j i j.,j __j __j .___1._____J __j _.J _J INFRARED HEATER S I __j __ _J —j __J _J __J __j . I J _.._l ._.__j __-1._ __.j LABORATORY COCKS_ f _j mJ _ I J --i ---A .,____J ____J _--_J � ---j MAKEUP AIR UNIT __j __j __J __j ___j __j J .-_.J ___1 __j __.f ._.J __.1 _ _ I __j OVEN .-J ---j ---i -i ____._J _J ---j ---.i __.-__! _....-_j --- -1.___.. _.i .____j ____ I ---j = POOL HEATER —J --i __ _ 11--i i __j __j I TJ —il- I _____.1. _j I _J --- ROOM I SPACE HEATER 1— I _-_J --- i ____J _-1®I __.____._.i _ _.I _....j _-1—j __ __j __j ROOF TOP UNIT ___j __j —i -_=J __j __j __j _ J I —J —J . I __J .-_-..J .—_.1 TEST __j .J .J ___j ___j . _ _ _1 __j ____-J UNIT HEATER UNVENTED ROOM HEATER ) �J �TI ,_ 10.-� T 1 �_-1--JI--J __ I ____J .____.! ____al L- 1 __I WATER HEATER __I ...—_.J __j __j j __.__l _ _j I I ® ! .._,__Jj .-J %I .Tj _— i --i OTHER __-__-1--i ---i ---i --i _—.J — —i .— --j. I .—.._.J ---i .._4-j TEST AND REPACE GAS METER PER I mm -1 _ ___ f - # _ _ _. -4'-d � �.� �,J .,.._-�i ____J _____ . ___FIFO DEPARTMENT/GASCO.MP_ANY��J „— 1 ___.j __-J —J —J �I i --_.__I _ 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ®✓ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F.71 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 E] 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 tru nd accur a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in come is ce with al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME DANIEL A LOMBARD III ( LICENSE # 15192 SIGNATURE MP✓® MGF ® JP M JGF ® LPGI © CORPORATION Q# 2999 PARTNERSHIP ®# � LLC M# COMPANY NAME: LEXINGTON PLUMBING & HEATING INC. { ADDRESS 169 SYCAMORE STREET CITY WATERTOWN { STATE MA I ZIP 02472 ITEL 617-719-7936 { FAX � I CELL 617-719-7936 1EMAIL LEXINGTONPLUMBING@COMCAST.NET ICU v The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Name (Business/Organization/Individual):X it 11 ��y_S� c (' -j �!� TAC_- Address: NiA_ City/State/Zip: -. Phone #: (a*+ �' ` 7 Are you an employer? Check the appropriate box: Type of project (.required): 1. am a employer with �.. ; .employees (full and/or part-time).* 7. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑Demolition 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t I 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10E] Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. FJ Electrical repairs or additions proprietors with no employees. , ' 12. ❑ Plumbing repairs or additions 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. ❑ Roof repairs These sub -contractors hale employees and have workers' comp. insurance.; 6.❑ We are a corporation and its officers. have exercised their right of exemption per MGL c. 14. ❑ Other 152, §1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check thisbox must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities ,have employees. If the sub-coritractors have employee`s, 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 jab site information. Insurance Company Name: L ` kCO3_ �'� Policy # or Self -ins. Lic. #: % Expiration Date: �� , Y►�` Job Site Address: la®� ��\ 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 MGL c. 152, §25A is a criminal violation punishable by 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 thgial'ator.�A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance I do the information provided above is true and correct. 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 Information and .Instructions w 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 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia a - Date Town of North Andover Your permit has been sent back to you for the following reasons - 1) Check amount incorrect 2) No copy of current ' ..--r"".. 3) Insurance Binde of on file r expired /. 4) No Workers' Compensa i Insurance Affadavit Form ✓ Please call with any questions 978-688-9545. Fax 978-688-9542 Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845 oma% ~ 1'S Date........ . ............................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION `A This certifies that ........... .......... t .................. !A ............................................ fi has permission for gas installation4mg.x".)A� .................................. ;in the buildings of ....... I ...................................................................... at ....... North Andover,Mass. 2z Fee .... P ............... Lic. No . ................... ... ! - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY MA DATE ' /.SII PERMIT # - - s JOBSITE ADDRESS j,, —0 G►/� - r OWNER'S NAME ADDRESS TE 7 $---Z 0 -73a FFAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW43 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F--] N010 APPLIANCES 7 FLOORS-- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - _ - J=D — -� . _ - 1 u (1 ... _ BOOSTER - CONVERSION BURNER -- __ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR, FURNACE - -- --- --- - -- - GENERATOR �_..,1_L-._I I GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT IN Ply — 1�!l �I��_ I I I �I� Mj11�ja■�4LWWL m�INWWW1WWP—F=II UN11T HEATER FW -1 1, UMVENTED ROOM HEATER MAI_� WWWW WATER HEATER —MMWWWWMWWWWMWWW 4 WWWWW W W WW WWWW wwwwwwwwwwwwwwwl' INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES jo NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY E] BOND 01 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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 with all Pertinent provisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAME eai�� .1 _ LICENSE# ,2SIGNATURE MP El MGF 0 JP JGF © LPGI ® CORPORATION ®# = PARTNERSHIP 0#[=7LLC 0#= - COMPANY NAME: _y ADDRESS ®- /-- _ t�, CITY STATE ZIP TEL FAX l= CELL ___--ve� EMAIL/ a rti W O H H U W a rA w^ \ll i O❑ z y ❑ C)00 w H � � w [�- a Z w W � � Un a W 5 a o > w W w U a o a a a U J E,, a CL x w F w H °z z 0 H U W C C�7 Y °a The Commonwealth of Massachusetts - Department of Industrittl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):� Address: / City/State/Zip: 14V Phone #: r Are you an employer? Check the appr 1. ❑ I am a employer with employees (full and/or part-time).* 2. I am a sole proprietor or partner- ship and'have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t riate box: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -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.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions l 1.lumbing repairs or additions 12. Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. / _/j Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date:,,/ 1 ff Z1Z Job Site Address: /6�i. �f� ✓�� City/State/Zip: f%j ,iS'l ✓lam li�� iii = �` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby cern under the pains and, that the information provided above is true an correct. 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 #: 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 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 CommonwoalthofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., M,A, 02111 TO, # 617-727-4900 ext 406 or 1-877rMASS.AFF, Revised 5-26-05 Fax # 617-727-7749 vaww.mass,govfdaa L1MNIONWEAL TH OF MA SSACHUSEi7-S WNW PLUMFI RS .AND GASFITTERS _ �ICENSEU AS A.JOURNEYMAN FLUMC3E ISSUES THE ABOVE LICENSE TO ' t -JEFFREY: IR�Y/DIgMOND 2 FOLEY ',DR : #� k � t :N READING hiA;*01864-150 a I :22489 05/01/14 21 348 ; \' No 1 v74 Date...... . /�1.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ��`' 0 S e E `� G`� tQ < L ................................................................................... has permission to perform ................. ey'.!.� .................. wiring in the building of . !1...... C.. i .�.. (%4 .... . . ............................... at J;k.0........9�f.. QR ..................... . North Andover, Mass. Fee.oe '.'.. Lic. ............................................................................ ELECTRICAL INSPECTOR Ck 6 70'6710198 10/98 10:57 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 'office use Only The Commonwealth of Massachusetts /C__ Department of Public Safety Permit `°. BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12003/90Occupancy°°Fancy a fee Checked —�-" (leave blank) PPLICATIONtoFORmPed ERMIT TO PERFORM ELECTRICAL WORK All workrdance h the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT OR TYPE ALL INF ION) Date- �— �° City To . ��J�� To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described h4-1nw Location (Stree Owner Or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ❑/ (Check Appropriate Box) Purpose of Building o Utility Authorization NO. Existing Service Amps Volts Overhead F] Undgrd ❑ No. of Meters Nev Service � O Amps J Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity7 Q Ur'r-'-4 Location and Nature of Proposed Electrical Work G� � � ��✓lG«G No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators RVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No, of Sounding Devices No. of Ranges Total No. of Air Cond. tons No. of Disposals No. of Heat Total Total Pum s Tons KW No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local ❑ Municipal Connection❑Other No. of Water Heaters KW No. of No,nof Ballasts Sisng LowWirVoltage 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. YES 0 NOE] 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. INSURANCE B BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work S Work to Start Inspection Date Requested: Signed under the penalties of perjury: FIRM NAME RESPONSE ELECTRTc SRRVT0V Twin Rough Expiration Date Final LIC . NO - -J F 7 d 4 A Licensee tilvinL)LIX 5 DEPRIZIO JR Signature 1-1 LIC. NO. Address 153 MAIN STRFET� MEDiO Rnr M-01 55 Bus. T No. 7R1� 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) O a Telephone No. PERMIT FEE S ��- Signature of Owner or Aeent Location -12e, �.�-- No. /o Date /7 a2-1-? TOWN OF NORTH ANDOVER Certificate of Occupancy $ '�sa�•�„5 <� Building/Frame Permit Fee $ Foundation Permit Fee $ cam/ Other Permit Fee $ TOTAL $5 Check # 177, e 13555 / ` Building Inspe`' V - N N TO T v .G Z Lw V] N O -- z U Zol Fji - W � W o C W Cn V) a w '� O O O U a U U G pr cn Z W O F ❑ F ❑ F H U V C7 tCj - O ^W C < = W W W U D O g V G O h .H n L (� EroO cn W 4.C Q O y O U U O U � ❑•� o a° O o z z i� C w y z O h C F �,. 5 ❑ c ❑ ❑ W a c0. C tcai O' W C W ..7 ... N L Z G7 W N ❑ ❑ q Z h G rO U N G w ' V11 Q z 7 j U w w w < U F W � C U !- ❑ � � O O .F.] .0 z -n y U "I C W U w U W U Z Z z U O C W Z ` z Z 22 V1 V] w '• (n L _� VI In VI V - N N Lambert Roofing Co., Inc. • 37 Stevens St. Haverhill, MA.01832 (978) 374-9224 for Toll free @ 1 -888 -SOS -ROOF In Business Since 1932 Dear Homeowner, Lambert Roofing Co, Inc. is proud to have the opportunity to bid on the following Residential Roof Construction. We are a quality -contracting firm and enclosed is proof of our professional status. The following enclosed documents are: _Overview of our Company Contractors License Liability insurance Workers Compensation and employers' liability insurance We are Members of the Better Business Bureau and many other quality assurance programs and would love to make you & your family another one of our happy and satisfied customers. F Co., Inc. "Quality Workmanship You Can Trust" Our proof is on your roof. �� 1 5 4.4 DEPARTMENT OF'PUBLIC SAFETY 159 f� I ONE ASHBURTON 'PLACE, RM 1301.1 BOSTON, MA 02108-1618 CONSTRUCTION SUPERVISOR LICENSE Nuoiber: Expires: Biri" "A e. CS 026791 0111712000 Rc--,tricted TO: 00 RONALO C 1-:111-18JERf "7 STEVENS ST J HAVERHILL, MA 01832 Keep top for receipt and ChaT19C.- of address notification. 7 -7 j HOME. IMPROVEMENVCON TRACTORS.' REG -I TRATION Board of Building:Re la:ti ­ - d.::'Standards. qu one an .-,�' One Ashburton Plape;'.*- Room. 13 .1 Boston,. Massachusetts, 0210¢: HOME IMPROVEMENT CONTRACTOR :- -- Registration 121981 Expira.tion,07/05�`/`�OO*.-'..,,. Type - PRIVATE CORPORATION. LAMBERT ROOFING - CO '.INC .RONALD G .. LAMBERT - A r 37 STEVENS ST. HAVERHILL MA 01830 J), LAMBERT ROOFING CO., INC. 37 Stevens Street Haverhill, MA 01830 (508) 374-9224 FAX (508) 521-5791 %j i i i;i......::::::::: ::.:........................................... ::: /� ti^':i' : : .::: .:. :•: i:: :.:. .. iiii..:iii ':: µ:':.......:: :•::........ :.i..; .i:tin':.: :..: :::.: ...::::::: •.::::::. ii:•is4:^is4::•:::'ryi::::h}}}i}iv::::::.�::::::•::M.;......................................:. ;i;i �(� iii'c' ;i:::.;... `. is C<: -- ;:>: ;:::::::;—i>:;i ;:;, ': — yii; y;S :;: :ip:.. :i ?'•i :•i :::. '' :ilii: °.. i::ii DATE (MMIDD/YY) ;:...,.:: ;::::: :i:;t»i;o->::;i;;i;:iiiiiir. 11.►t::.ii::::i:::;:;::<::;::::;:;o:•:c :. .. .. ;.. .,.:;•. .>::: .............................::::::::::::.:.>i:.»i:•>ii:•i>:.>:.i>:.>:.iiiisi:.i>i:.i:.>i:.>:.>:.>:.is.i:.>i:;.>ii:iii>ii:;•>:•ii:•:>iii:•ii:•i:•:ii>i:•>i:;:.�:::::::::.:::::::.,.::.::,:::::::.:;.>:;.i:<•i:.»�::�:.::�::.:.::.....................:. .....................: ..... 10/22/99. PROUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BOYLE INS AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 445 MAIN STREET COMPANIES AFFORDING COVERAGE WOBURN MA 01801 COMPANY A TRANSPORTATION INSURANCE CO DIBURED LAMBERT ROOFING CO INC MERRIMAC VALLEY ROOFING CO INC 37 STEVENS ST COMPANY B TRANSCONTINENTAL INSURANCE COMPANY C HAVERHILL MA 01830 COMPANY .....: . D ><::;?:::'?:'.:.::':::::::>.i»»»»:::::::::>:>::>::::>:::.i>:>i::>::ii>>::i:>:i:<:::iii::i<::>:::::i::»::>::>:::<::i::::i»::>:«::<:>::::>::»:::;:;;:i::iiiii:•i:•i:;.i: ii:.iii:.i;iiii:.i;:.i:.;:.;>:.;:.i:;•:.;ti•;ti.ii:::..:::::::::::::::::: :.....................................::......::•::.:::•::;;:::::::::.i:.::::::::::.:.iii:•i:•i::iiii:•i:•:•:.:.i: ...................................................:: �:•:•::•::;:.:.;;:.;::i::::i;<<:�»::::::»::»»>::si<i::::<�::>:<>i>::s>::»>i::::::»:<:;»: �>::s::>::::»:;:s:<':>:::<ii: 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. DO LTA TYPE OF INSURANCEPOLICY POLICY NUMBER EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE rx OCCUR 0174 0 2 9 9 5 8 5/28/99 5/ 2 8/ 0 0 GENERAL AGGREGATE s2,000, 000 PRODUCTS - COMP/OP AGG $1, 000, 000 PERSONAL 6 ADV INJURY $1,000, 000 OWNER'S A CONTRACTOR'S PROT EACH OCCURRENCE $1,000, 000 FIRE DAMAGE (Any one fire) $ so, 000 MED EXP (Any one Person) $ 5, 000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per Person) HIRED AUTOS NON-OWNED AUTOS BODILY denq INJURY (Per aoci$ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM __572­8 EACH OCCURRENCE $ AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS' LIABLLY WC179 4 0 6 2 5 0 5 2 8JT9 9 00 X TORY LIMITS ER EL EACH ACCIDENT $ 100,000 THE PROPRIETOR/ PARTNERS/EXECUTIVE INCL OFFICERS ARE: EXCL OTHR EL DISEASE-POLICY LIMIT $ 500,000 EL DISEAS00 E-EA EMPLOYEE000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEMWAZ.LSPECIAL ITEMS <::: '. :..::::::::::::::.......................... •._ :::................::•::.:i�•»>::ii::; �i:;;.i:.ii:.iii>riii:•>:.iii::::::::::::::::::i::.i:.ii:•i:.i:.>:.:;.isai•:::::::::::.;.::oi:.i:.ii:.:;.::.:;.ii:.ii:oii•::. :.;•:::::::::::::::.::::::::::::::::::::::...................................:. <.;ii:.i:.i:.i::.i:;:::::.:::;:;.:.i:.i:.i>:.i:.i:.ii::.r:.i:.:.i:.is:;:::::::::::.i:.>:.:;.i:.ii:;.iso>:.iii:.i:.i:.i:.>:.i:.i:.ii:.:.: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE LAMBERT ROOFING CO., INC. EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 37 Stevens Street I_Q_ DAYS WRITTEN NOTICE TO 7TH CERTIFICATE HOLDER NAMED TO THE LEFT, Haverhill, MA 01830 (508) 374-9224 FAX (508) 521-5791 c :.:::::...::..::::.:::::::::::.:::::..................... ..... St'v. .. 1<:>:>::>::::::::i:::<:::i:<:::?:«:::i::::::a::::<:::>:>:i:<:iii::>::i:>.:>::»::>::»:»:::;:<.;:;:•;:.i:;.::.;ii:.ii:.ii:.:;.;:.;:.;:;:•;ii:.;:.i:.:::::::::::::::::.�:.::..:::::: BUT FAILURE TO MAIL SUCH N SMALL OSE N OBLIGATION OR LIABILITY OF ANY KIND UPON OMP ITs AG OR REPRESENTATIVES. 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