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Miscellaneous - 121 CAMPBELL ROAD 4/30/2018 (2)
121 CAMPBELL ROAD /// 210/1068-0036-0000.0 I 'i S. T' t v r �I Date...I..(... ... ................ NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING U This certifies tliat ..� &-I-i ......................................................................................................................... has permission to perform .....A./C— Lkrl_114 .. ................................z........................................................... wiring in the building of.......- XSe U 4 A---Q. ... ......k. ..................... .............................................. at ........ orth Andover Mass Fee.--,)..ab ........Lic.NA . nk.....g ...... CAL IN PEcroR Ch;Gk# 11991 �' : � 4 '.�. K Commonwealth of Massachusetts Off`ici/a�l�Use Only ~ Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code EC) 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ///? /3 City or Town of. NORTH ANDOVER To the I Zpector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) f (f a410691& Owner or Tenant J� F-ynVic LaTelephone No. 66jr Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 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: T Completion of 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 No.of Luminaires Swimming Pool Above ❑ In- 1:1o.o mergency ig ting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Q Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Dis posers HeatPump Number Tons KW.......... No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Dr Heating Appliances KW Security Systems:Y y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) WWk to Start: 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 e`—B—OND ❑ OTHER ❑ (Specify:) I certify, tinder the ains and enalties of perjury,that the information on this application is true and complete. FIRM NAME: .)&Z,h Wovclll. LIC.NO.: Licensee: t jgA .t� Signature LTC.NO.: aI6 (If applicable,enter "exempt"in the license number line) Bus.Tel.No.• 5199`162-1-NAP Address: 12t0 /ai s771t-c1 N" 034i Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally b required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. �-- Owner/Agent PERMIT FEE: $ _ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed x on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. I ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed 0 Re-Inspection Required($.)❑ - Inspectors Comments: r" Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed '❑ Re-Inspection Required($.) ❑ Inspectors Comments:,—, Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com F . The Commonwealth oflMlassachusetis Department of IndustriglAccidents Office of Invesfigations 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): Address: 9 %Qom✓►nMC,1c K P- City/State/Zip: P/a, 5TZX-i NR �J� � Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. n New construction ees and/or part-time).* have hired the sub-contractors to full d/ p Y ( p ) 7. E]Remodeling el listed on the attached sheet.� 2. m a sole proprietor or artner- p p p 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.El I am a homeowner doing all work rightexemption per MGL 11.F1 Plumbing repairs or additions of p tion myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 Homeowners who submit this affidavit indicating they aid doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lam an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lie.#: Expiration Date.- Job ate: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 requiredunder 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 ofup 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 hepeby//cert under the pains andpenalties ofperjury that the information provided above is true and correct Date: 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#: J - Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or loeal 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 anLLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe 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 homeowner 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 of1\41assachmetts Department ofIndustrial Accidents Office of Investigat:ions 600 Washington.Street Boston}MA 02111 TQL#617-727-4900 e�,t 406 or 1-877:MASS-A.k'B Revised 5-26-05 Fax#617-727-7749 www-mass.govaa A w r - , S . %i ':COMMONWEALTH OF MASSACHUSETTS>: >_ • • - OIN • I al m IN LOV4 1-11 E=L:ECTRA'C"IANS SUES TH,E„.;;:FOLLOWING ta'CEN RE:GtSTERE`D MASTER :; 'LECTR.IC�I�AN AiN< M B O U C H E R:;,SR I 2 TA � z M ACK RD �.`�:.�' ;� W I J NH 3865 27,74 .....:,. 77997 ;. II a '.ti � �` "� 9958 3 �� /l .t Date.................................. r IORTII, 00 TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ��SS�cNU This certifies that ............ v .... . .� . :�..................... has permission to perform .......... (J ..I wiring in the building of.......l.:.... K L � 1. Z! �'�1.�r 2 t► at...................................f1�cz ...............�.......... .. ,North Andover,Mass. 70 -- Fee.... 3 5......... Lic.No...�17305................. .x ` ....... CTR ICAL BCTOR v Check # ... s J ` COMMOnWealth of-Massachusetts Official Use Only Department of Fire Services Permit No. f 91 F BOARD OF FIRE PREVENTION REGULATIONS OccupancyandFeeChecked p ® [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Ail work to be pertormed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 PLEA SEPRINTININKORTYPEALL INFO TION) Date: L-2:� --- /O —// City or Town of: W�top To the Inspector of Wires: By this application the undersi ed gives no ' e of his or her intentionerform the electrical work described below. Location(Street&Number) /a/ C4 Y,f6,,�F-L(-, �� ,�/ Owner or Tenant . LTL �/�/.�'T� f�D2 �U /'��1�� /T�iCJ Telephone No.�im13 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ BLDG PFRNUT# Purpose of Building Utility Authorization No. Existing Service z;fOy Amps / y Volts Overhead Und rd g No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: � ���, Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires a No.of Ceil.-Susp.(Paddle)Fans No.of Total. Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires ' Swimming Pool AboveElIn- o.o mergency ig ttng —,rd. nd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches No.of Gas Burners No.of Detection and Initiatin Devices No. of Ranges No.of Air Cond. TotaTons l No.of Alerting Devices No. of Waste Disposers Heat Pump Number_. Tons. KW No.of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other r� No. of Dryers Heating Appliances KW Security Systems:* No. of WaterNo.of No.of Devices or Equivalent Heaters KW No.of Data Wiring: --� Si s Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent 80 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0 0_ (When required by municipal policy.) Work to Start: --I Q-1 I 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 suchv rage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE DO BOND ❑ OTHER ❑ (Specify:) I certVy, under the pains andfen"bldes ofperjury,that the information on this application is true and complete. _ FIRM NAME• ,PIS F�lUELI~CT �R/l.i LIC.NO.: Licensee: 5 fj��� Signature (Ifapplicable, enter "exempt"in the license number line) LIC.NO.: ;V'vAellf Address: J5 , !y/C� I�Q y Bus.Tel.No,ZU-, (ob"1,$ � *Per M.G.L c.147,s.57 61,sec ty work requiresDepartnient of Public Safety"S"Licen � ; OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. 13y my signature below,I hereby waive this requirement. I am the(check one)❑owner Owner/Agent ❑owner's agent. Signature Telephone No. PERMIT FEE: $ ' ELECTRICAL PERMIT NO. INSPECTION REPORT: ' ELECTRICAL INSPECTOR-DOUG SMALL ` 1.ROUGH INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 2.FINAL INSPECTION: Passed— Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors'comments: (Inspectors'Signature-no initials) Date 3.UNDER GROUND INSPECTION: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] 1 Inspectors' comments: (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date 5.INSPECTION- OTHER: Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ] Inspectors' comments: (Inspectors'Signature-no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED. v The Commonwealth ofMassachusetts Department of Industrial.Accidents 'IROffice of-Investigations 600 Washington,Street Boston,MA 02111 �"� s�' www.mass.gov/dia Workers' Compensation I[nsurance Affidavit: Builders/Contractors/FIectriciaus/Piumberg Applicant Information. )Please Print Legibly Name(Business/Organization/Individual): 4JZ1J Address: City/State/Zip: Z_\1 rJ K3, El 4 . Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am.a employer with 4. ❑ I am a general contractor and I 6. ❑Now construction employees(full and/or part time).* have hired the sub-contractors 2I am a sole proprietor or partner listed on the attached sheet.s 7. ❑Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its g 9. Electrical repairs or additions required.] officers have exercised their 10.F1 3.❑.I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing.repairs or additions myself o workers'comp. c.152, 1(4),and we have no Y [N p § � ) 12.❑Roofrepairs insurance required.]T employees.[No workers' comp.insurance required.] 13.El other ?Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. j fcontracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I -fain an employer that isproviding yvorkers'compensation insurancefor my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self--ins.Lic.#: Expiration Date: fob Site Address: City/State/Zip: 1 l Attach a copy of the workers"compensation policy declaration page(showing the policy number and expirations date). 'Y 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido herebyM/,� , un r e ains and' e�a1, ofperjur-y that theinformationprovidedabove is true ande rr eet.Si ature: Date: F5 i Phone#: E only. Do not write in this area,to be completedby city or town official.ns: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector son• Phone#: I Y ji i � � Date.. . /l . . 8872 TOWN OF NORTH ANDOVER ° PER IT FORPLUMBING CMUSEt This certifies that . . . S . f. . . . . . .Y!—. . . . . . . has permission to perform . . . . . <'wt%.� .44.'/r-. t . . . . . . . . . . i plumbing in the buildings of . . �- '-i '. .!!!` . . . . . . . . at . . .P'.f (:;7 06'.!fV?h.z .. . . . . . . . ... . ., North Andover, Mass. Fee. 1ff.7. ��.Lic. No.. � ©. . . . . . . . . . . i-.�.� ` `��.. . . . . . PLUMBING INSPECTOR Check ." / G d i i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: .17)n"A ,MA. Date:.ky T / I/ Permit# Building Location: o- L' 4�►�l �� `� YY Owners Name: &T L-C /yo4 k 1 k/dl Type of Occupancy: Commercial ` ❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:M_""Re lacement: p ❑ Plans Submitted: Yes❑ No FIXTURES DEDICATED LU z SYSTEMS f- z F7 Z y O Ln Y U � wz N N N c C Z F' Y Q Vf -i U ~ W = Z Q N x y LU Q = z F- W z F- Q Ln Z D Q H w W W iA H Q it �- N F- [n N OC Q Vf Q H 0 Q z C 0 C C' Z Ln Vf U O. U L61-- ?� 0 D: �, W 0 F- 0 W in J J Z C d' 0� W > W U r"' 2 d O I.- U z Q 0 d Y z Vf F ►- W y W LU LU Q Q N N O 0 F > > O = Q Q Q Q Q fix.. U Ln Q Q Q oD m c o LL x Y g SUB BSMT. BASEMENT j 1sT FLOOR 1 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TH 7 FLOOR 8T"FLOOR —�-- ( Check One Only Certificate# Installing Company Name: LAAy�l (f �j�l��✓vt_ /? Address: _0,15k o n 54 city/Town: /✓@may State: ❑Corporation �A ¢ ❑Partnership Business Tel: �l 0-�/�-.�"'��g Fax: Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes F No❑ If you have checked Yes,please indi to the.type of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of m Knowledge and that all plumbing work and installations performed under the permit issued y P ed for this application' Pertinent r pp tion will be in compliance provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. phance with all By Type of License: ` Title Plumber Sig ture f kLUIcens�edPlu�mber City/Town ❑� Boaster APPROVED OFFICE USE ONLY Nriourneyman License Number: \30111 i The Commonwealth of Massachusetts c � Department of Industrial Accidents Office Investigations .ff of nvesti g ��• 'M 600 Washington Street • i ilii �.� Boston,MA 02111 www.mass.gov/dia f . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Prinf Legibly_ Name(Business/Organization/Individual): 6""' Llubt^ Address: 7 aS,,Al,,ar\ s City/State/Zip: e e v-e I Phone Are you as employer?Check the appropriate box: Type of project(required): 1.❑ I a a employer with 4. El am a general contractor and I 6. ❑Ne construction tnployees(full and/or part-time).* have hired the sub-contractors 2. I arnt 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 required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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.E]Roofrepairs insurance required.]t employees.[No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certrfy nder the pains andpenalties of peijuty that the information provided above its true and correct.' Si natur Date: 0 Phone#: 21) 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 entityy or an 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.ees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the 9 dwelling house of another who employs ii p Ys Persons to do maintenance,construction or repair work on such dwelling house q 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 perfonnance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." ;I Applicants !I Please fill out the workers' compensation•affidavit completely,by checking the boxes that apply to your situation and,ifL necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of 17 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 f employees,a policy is required. Be advised that this affidavit maybe 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 pen-nit or license is being requested,not the Department of i� Industrial Accidents. Should you have any.questions regarding the law or if you are required to obtain a workers' 'i 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 Deparhnent 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 pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple,pennit/license applications in.any given year,need only submit one affidavit it « Y v 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 pen-nit 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: I The Commonwealth of Massachusetts Department of Industrial.Accidents Office Of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877 MA.SSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Fold,Then Detach Along All Perforations .COMMONWEALTH OF MASSACHUSETTS i •. •. • IMPORTANT NOTICE LFATE OWNED INSTALLASIMUS TBE FILED AT THE OR USED LICENSED AS A JOURNEYMAN PLUMBER INSTAFACILLATIOS FOR PLUMBING AND GAS FITTING ! ISSUES THE ABOVE LICENSE TO I OFFICE OF THE STATE BOAR i JUSTIN C SULLIVAN 1.6 !� m' ,I 43 FRONT I BEVERLY MA 01915-5010 I ! 30119 05/01/12 80009:5 g All Perforations V Fold,Then Detach AlonI E i { ! I I - i I I I �� C f f I 6251 Date. ......................... NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACHUS� l This certifies that .................... ..,:................................... ................................ 3 has permission to perform_.......' .. {-w wiring in the building of... .._.. .........''......�� ��.�'............................... atl.. ........ ..........:.......................���.............. ,North Andover,Mass. '. Fee d............... Lic.N ............ . ..: . ............. .......... .................... ELECfRICilINSP R Check # JaA ._—_ ft 1 C Commonwealth of Massachusetts Official Use Only Permit No. Z 2-5;G Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. n/99j eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in somrdance with the Massachusetts ElWdal�(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL RMATION Date: "Dzp—. \ a o a ,-,7 City or Town of: K) nkZ\3 Lr 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&Nu°ber) - Owner orTenant (--36,sN- Telephone No.C1_A btYJ (,,k6 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building UtilityAuthorization No. Existing Service ©O Amps k1J0 l a\-(OVolts 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: „�t,�k —�J ���r►, on the ollowi table be xrolved the I iPtrec f Total No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans 'Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of LJghtig Fixtures SwimmingPool Ve ❑ r-1o.o memucY • ug d. umd. Batt Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS Ne.of Zones and No.of Switches No.of Gas Burgers o.o t Initiatin Devices No.of Ranges No.of Air CorA Tons No.of Alerting Devices No.of Waste Disposers Hed eat No. um r Togs De oectiod er Devices No.of Dishwashers Space/Area Hating KW Local ❑ Cognec�ion ❑ Other Security ' Ko.,of Dryers .. Hating Appliances KW No.o ems. or Equivalent No.o a erKey o.o o.o Data Whin . - Haters Skus Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors 'Total HP No. Telecommunications f Devices or uh4llent OTHER: �� o^d Anaek addbionat depart(/deskrA or as re uk-ed by oke Impeder of Wino. 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 is in force,and has exlu'bited proof of same to the permit issuing office. CHECK ONE: INSURANCE LTJ' BOND ❑ OTHER ❑ (Specify.) ,O)O I., — c� (Expiration Date) Estimated Value of Electrical Work: �'0'0. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify,tender thtpalns and p 7!\akies ofperJury,that the lnJbrutadon on Arts application is true and complde, M FIRM NAE: 5 L Nle \t_CA 6% t0J 2.T i1'." LIC.NO.: 4 2- Licensee:�1\Q U t� S c.0)k Signature LIC.NO.• 5 (Ifapplieabl4 enter" t"in the licensenuntberline.) Bus.TeL No.- Address: 1�l n�� e�f 1 u��S�vN \�1 Alt.TeL No.; OWNER'S INSURANCE WAIVER: I am awake thit the Licensee does not have the habrhty insurance coverage normally requirrA by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent, Own ,/Agent Sign ure Telephone No. PERMIT FEE:a �-c .. .,,.4 Y f �� Commonwealth of Massachusetts Official Use Only Permit No. �,�� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. l 1/99] ea1e blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfaaned in accordance with the Massachusetts MeddW COeC).527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL RMATION Date: D Z City or Town of: !tea 1) \!t4- To the Inspector of lyres: By this application the undersigned gives notice of his or pea intention to perfonn the electrical work described below. Location(Street&Number) \ k U\n\&W Owner or Tenant � � �-y,nc ��� w Telephone No.`1'1`��.•�E �l`6 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building U�uthorization No. Existing Service �©D Amps 1�� / �OVohs Overhead Undgrd❑ No.of Meters New Service Amps / Vohs Overhead❑ Undgrd❑ No.of Meten Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: CW"PWorithe ollowi table be wgived the I o Wins No. Tota No.of Recessed Fixtures rl No.of CeML-SoV.(Paddle)Fans Trrannsformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA ale 1 No.of Lighting xtures Swimming Pool d e ❑ d. ❑ BaNo.o Unizmets>uY ng Fi No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches Na of Gas Barnes o.oecu t Initiatial Devices tal No.of Ranges Na of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eaed Toun talsp um er ons De0.teoctios/ on Devices Munlelpal Na of Dishwashers SpacelAres Heating KW Local ❑ Connauon ❑ Other security Heating Appliances KW Systems: NO.of Dryers . . No.o or Equivaknt No.of Water KW .o.of No.of Data Whingg�.• � Heaters S Banasts No.o'(' or Equivalent No.Hydromassage Bathtubs No.of Motors 'Total HP Teleco of Devices katioo 0"IVa lent OTHER: � u� �,,,,\d AneA add(tWW ddatt tf deskeA or as repwtrad by die Igor of Wikrm INSURANCE COVERAGE: Unless waived by the owner,no pamit for the performance of electrical work may issue unless f the licensee provides proof of liability insurance including`completed operation"coverage or its substantial equivalent. The undersigned certifies that suchn force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE7BMOZ ❑ OTHER ❑ (Specify./ O O (ftpiration Date) Estimated Value of Electrical Work: �'0 (When requited by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cerdfy,ander thgaLw and peva/des ojperjur,►S that the lnJbtrrtadon on thls app/lcadon is true and complete. FIRM NAME: 4�L 3 r zCA r*k 2.t`J . , LIC.NO.: D-'00i .Z _ Licensee: Q v1 E S c o Signature LIC.NO.: X;�' f 1 us.Tel.No.. (lfapplicablc enter" t"in the lieensenumber line) B ` Address: 11 c,.� wt�f. 1 �;��'S1ayN �� \�1�j Alt.TeL No.. OWNER'S INSURANCE WAIVER: 1 am awake thit the Licensee does not have the liability insurance coverage normally requirrA by law. By my signature below,I hereby waive this mpdrement. I am the(check one)❑owner ❑owner's a nt. Owrt /Agent Siglioture Telephone No. PERMIT FEE. $ t 35 i �� ' - Jnr.•..�,'.^"s'' ��±e�+e.«.rtit"�M!9s ".'+rx..,,,,r-vr-K.*,.. _,_ .....�. _ ,... ....-� fi Location No. ✓ Date _ i 3 �oRT� TOWN OF NORTH ANDOVER p f 9 re ` Certificate of Occupancy $ Building/Frame Permit Fee $ swCHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �7r ' 18751 �F' Building Inspe6 r y TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCTRLP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: e S I NA / S G TURF: Building Commissioner/I r of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map N Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin District Proposed Use Let Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rapired Provided RecNired Provided 1.7 Water Supply M.CLL.C.40. 54) 1.5. Flood Zone lnfomntion: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ --q . SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No M 2.1 Owner of Record f�CT'fktQ �n/G�,tyu�cJ 12 r—r�Prs�.�� Name(Print) - Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O .�.�+ R License Number A ss D Expiration xp n Date ic� Signa Telephone '... 3.2 Regi Home Improvement Contractor Not Applicable ❑ 0 md&�e"� Company Name Registration Number rwrn Addre r G z-0f-0 _ Expiration Date Z Si na Tel hone SECTION 4-WORKERS COMPENSATION(M G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) . ❑ Alterations(s) Ef Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: tnLAR S-H &9WEy7' Lc�t,✓P 4r/Ear�S tLS1Jt�/—/n�s�f�ryC �� � 46PM -M &r cu,E,, SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit applicant 1. Building (a) Building Permit Fee 38 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical HVAC 5 Fire Protection . 6 Total 1+2+3+4+5 2 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1> 9-77M* f'k"vDE,'�ra� ,as Owner/Authorized Agent of subject property Hereby authorize -106w 66(,,/ 40)x3 ./ 64—SY.S25;h 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 I, DWW/-Z5& - ®,tw-W-f aCiJ>nJ($ T 5,VS225�i as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the.best of my knowledge and belief awe 44WIL- Prin e Ano( afar Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD 71, SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DfMENSIONS 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 s NORTH '9 Town of : s over No.3 3 (o CONz-- A o dover, Mass., D �. I� COCHICHEWICH 7 ADRA-rED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT............ ..... ............ ..... ............................. Foundation has permission to erect.... buildings on ..../rV.............................. ................... �• Rough to be occupied as ............ .. Chimney provided that the person accepting this permit shall in e ry respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTI ST T ELECTRICAL INSPECTOR Rough ............... .... .. .... .... ... 4................................. 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. r �� �I f I� rUKm U - LU 1 KCLC#kQ= rvRm INSTRUCTIONS: This form is used to verify that all necessary approvals/permi 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. b APPLICANT FILLS OUT THIS SECTION APPLICANT� � �'rt�-�i1 - PHONE LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT(S) STREET /Z/ � �° � �o� ST. NUMBER 1�. OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS -- FJ;SE E CTORT --- DATE APPROVED DATE REJECTED PECT HTH DATE APPROVED a? r C DATE REJECTED J n t COMMENTS — - v PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT j1e FIRE DEPARTMENT R// Pete,;i � r Qejamr�� �¢�,.�_,*Idl- "ice., 101����,� 'ECEIVED BY BUILDING INSPECTOR DAFTE RECEIV Revised 947I OGT " NORTH ANDOVER COMMUNITY DEVELOPMENT&SVCS J NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL 11, S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: &eo Duxe.5— (Location of ' �,,) Signature of Permit Applicant Fire Department Sign Dumpster Permit Date I �, , r CONTRACT Customer Name-4kiAar t Z+ uiaN CuNo�eru' A) Customer Signature SKETCH Contract Date /0/5/0� Sales Representative Signature e�—uo/ r�� ATTACHMENT CustomerPhoneContract Price Z.Z X30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 r-19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 0 41 42 43 d4 45 46 47 48 49 50 51 52 53 5a 55 56 57 56 59 60 --r T tt - f- - � f 3.1 tf 4- 1_12 1 -E- 13 14 15 T17, _T— I6 - - - _ -! -E - - - „ F- 20 211 , , 22 23 24 25 176"VRVI� 27 i- 26 31 32 �- �+ -iA'7 r' <NCdaL :ov, GGtzcJN(�IQ`S�� NOTES: r pal7 L/ Each box equals one foot unless otherwise noted.This sketch isa good faith / le erI i / G representation of the work to be done, it is understood that all dimensions i derived from this sketch are approximate,and that all locations of outlets,light i P n F ( fi P ! ! fixtures,plugs,jacks and/or switches are subject to change if necessary. #F/lsLnn CG'.Nvoars'iNnv'i hr• Jnr;1ez�by CONTRACT Customer Name 4ki�Ir e Aygl"k4Qn7 Customer Signature SKETCH Contract Date /O&LO5� Sales Representative Signature (9:q.6a ATTACHMENT Customer Phone F7?-6911- 1619' Contract Price to 2'3 0 i �=S�^ 9 10 11 12 13 14 15 16 17 /8 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 JB 39 40 41 42 d3 44 05 48 47 dB 49 50 51 52 53 51 65 56 57 58 59 60 6 I 7 J ! Ace 9 #,o 11 12 13 I l 14 15 1 17 1 i 19 z - 23 V1f lP — zd POO 1 � 25 ..._--r i-- - -- ... - -- ---- -- -- — - -- ----- -- - — ------ : I 1 27 II 28 ' 30 � i 4. 31 . _ I t-_I- - -I I- l - - I f 32 _ fh" S N L( JL4/ �.C/.. -l' :..r-.___ � f �+ I /-�cracoa� ,Nc/u�es emo g x' .S J i _ .5�� —�--1 I � I �7 -- }I C T fr 1----- 35 f I l I 1 I /y 1 I I I i i i I I 1 i l NOTES: 4por,5 po (/ / 1k1Each box equals one foot unless otherwise noted.This sketch isa good faith / SA, b� representation of the work to be done,it is understood that all dimensions derived from this sketch are approximate,and that all locations of outlets,light ittlklp. Redica"I /VF P X, 6 / -e,"'! fixtures,plugs,jacks and/or switches are subject to change if necessary. F/r's Ln,9 GG',:v�n.95'iNny��1P env;ctl]/by OP CU/LS>�UPc.srou fo Xe in The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations "' 600 Washington Street Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 5a,1i✓C Address:- City/State/Zip: j� ddress:City/State/Zip:j� Phone #: *;?/'IiOD Are>09an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with � 4. m❑ I aa general contractor and I �� 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. * 7. emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *.Any applicant that checks box#l must also till out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. `Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: / � Zat?IL� Policy#or Self-ins. Lic.#: y�,�-�fS- fj[J�j�-j-d/�" Expiration Date: sz �� Job Site Address: ta) 6/t7� 4wo City/State/Zip:N, rayu�, � a05— 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 tine 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 her: Ir ertify and r 1l1 a' , a l Wallies of perjury that the information provided above is trite and correct. Si natuDate: l� Phone#: ��4`WAO Oficial 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): I. 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy 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 till 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 pen-nit/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. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia 05/26/2005 13:04 FAX 1 781 659 4725 Andrew G Gordon Inc _ X001 ,si moi evva t6:Ls MAGE 002/002 LI+1(i I.iuty Magma Grrup Lamrtv PO Boz 7102 mutua PadmwAt Nie 03802-7202 Tdephme(E00)653-7843 Fax(6013)431-5693 i My24 2005 I NADG MN do CO 9"TURNPUM ST CANTON,MA 0202.1- BE: Certificate of Workers C.oq?emmxGm Iawrumv. lm=re& OWEM rMRNING FUMUM)BASEb1ENT %0 TIMNPOCE ST CANTON,MA 02021 PoficyNumber: WC2--3IS-344359415 EffeeOv= Sf24&tW Fxpiatim: S242006 Coverage afforded soda warps Cha Law oftha tonowmg statdsk MA Emolovas Usurer. BodityhyuryByAeadeat S 500,000 Each Aeeident BaftinjarybyiisemC S 500;000 Each Boditylnjimyk9Dimme: S 500,000 PaficyIii As of this data the poligbotdw is iomm byL&crtyMW=I Foe bum- etCar vadcr the policy fixted above. The imsonoaee afforded bythe feslod policy is sn6jad to all the term mcbmiaas aad cmc,aad is not altered by my regairaamt;tam or cmddoa ofaay or oder doh wiBr respect to VW&an oateficate maybe issued This c rtifie:ie is iow d m a aut[er of- fixnkmfiaa ally and omfas no**up=t upm Yu%the cue holder. This eerfificate is nd no insurance policyand does not amend exSendL ar Aber ibe coverage a6orded bythe policy&stud abatis If this policy is anceIInd t,fi ,the stated espiratioa date,Ubmty Mmud win tadeavor to mwfy ym of such eoaccuatim. K �tllaotttzPn�crwmrE IJBEn-Y>dLfftlaL nISURAI11E GROW ThkC"Mbi$4mwlftdyi2ZRTTSUn=ALUt=A7RMGi0�sa adivoeesied�teti��se�ins .. = lnstrod: Ptudocar of Raoard: OWENS CORNING F1N3 UM&4%SEWUWr ANDR W G GORDON INC 960 TURD ST P O 130%299 CANTON,MA MMI NMWEII.MA 02061 vzyiaas 05/26/2005 THQ 12_36 ITKM NO 51441 IM002 I Ivll 1.Lv GI11 WAN Ill l�u�/lul l.a•�J•••...+•u•Iw •onl✓.V 11 l.i�..-r.r 1... .....�• ....-........_._-_.. ........ ... ��... OP ID E DAA(FYI ACORD_ CERTIFICATE OF LIABILITY INSURANCE BAOPID 08/19/05 PRODucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kaplansky Insurance Brookline HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 114 Harvard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brookline tom► 02446 Phone:617-738-5400 Fax:617-738-8214 INSURERS AFFORDING COVERAGE NAIC# INSURER A- Norfolk i Dedham Group. - 13943 INSURER B: MA Basement System LLC INSURER C: D/8/A Own es Corniaq Finisbinq 960 Turnpike St INSURER 0: Canton HA 02021 INSURER E: - - COVERAGES THE POLICES OF NSURAIWX LISTED BELOW HAVE BEEN ISS"TO THE INSURED NN.ED ABOVE FOR THE POLICY PERIOD]INDICATED.NOTWITHSTANDING ANY REOURDAENT.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 CONDITIOdS OF SUCH POLICE'S.AGGREGATE LMOTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF NSURANCE POLICY NUMBER DATE(MMlDOrM DATE(NMOD" lUMrTS . GENEIVLMaLJTY EACH OCCURRENCE 1 $ 1000000 NHR.cERC1ALGENERAL LlaeLrtt PREMISES Eeoccrrenoe) s 100000 aaMs A-m ❑OCCUR MED E)(P(AM ane Person) s 5000 A X Business Owners EL0309626 02/10/05 02/10/06 PERSONAL aADvINARY s 1000000 GENERAL AGGREGATE s 2000000 GENLAGGREGATE LMT APPLES PER: PRolwcTs-coMP/OPAGG . $2000000 POLICYF—j MECT LOC AUrOMOSLE LIABLFTY COMBINED SINGLE LN OT s ANYMJTO (Ea eaidert) ALL OWNED AUTOS - BODILY WARY $ SCHEDULED AUTOS (Per Person) HIRED AUTOS BODILY NJURY $ NON40W ED AUTOS IPor aoadeal) - _ PROPERTY DAMLti(,E s . (Persaident) QTY - AUTOONLY-FAACCIDENT s . ANYAM E I HODER THAN A ACC 6 AUTO ONLY: A G s EXCESSAIMBRB.LA LIABILRY EACH OCC1UlfENCE $ OCCUR EICLAIMS MADE - AGGREGATE $ . REDUCTIBLE s ETENTION s _ Wtlf*%M COM fle"TION AND TORY LIMITS ER EMPLOYERS'LMBIIJTY . ANY PROPRETORIPAATTNERiEXECUTIVE EA.EACH ACCIDENT s OfFICERAAEMBER EXCLUDED'! IT IDSL des,,,;oe I.nde. E.L.DISEASE-EA EMPLOYEE s SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY FIRDORS9AFJtr I SPECIAL PROVISpNS - CERTIFICATE HOLDER CANCELLATION SH OUA.D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPORATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUJT FAILURE TO DO SO%WLL IMPOSE NO OBLIGATION OR U424 TY OF ANY KIND UPON THE ORSUREL rr$AGENTS OR . fEPRELENTATWES. TTVE AC 0 ACORD CORPORATION 1988 r 91te -Oo Board of Building Regula (ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reaistration: 137943 Type: Supplement Card Expiration: 1/29/2007 OWENS CORNING BASEMENT FINISHING DANIEL WALSH 960 TURNPIKE ST. CANTON, MA 02021 Update Address and return card.Mark reason for chang )PS-CAI G 50M•04/04•G101216E] Address [j Renewal [:] Employment Lost Card Tp V�o�,�mosuuea�D�i o�✓uaaaadueeel Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratlon:.,t37943 Rin of Building Regulations and Standards Pn %2�412007 One Ashburton Place R1301 Boston,Ma.02108 =Sllppfement Card OWENS CORNING BASEME1 960 TURNPIKE ST. CANTON MA 02021 Administrator Not valid without signature ✓ll.P, (;nR77L172fY/Ll(/(.'CGC�/L (lj i.•"(�.J;N[.ff16 BOARD OF BUILDING REGULATIONS ? License: CONSTRUCTION SUPERVISOR Number: CS 079893 Birthdate: 10/05/1962 Expires: 10/05/2007 Tr.no: 6491.0 Restricted: 00 DANIEL F WALSH 488 KENDALL RD G c, TEWKSBURY, MA 01876 Commissioner j- � ' 6 c� / �" /` —f/' 5 (p w Date. . . .... ... . ........ NORTH TOWN OF NORTH ANDOVER Of .,,ao ,s1ti0 PERMIT FOR GAS INSTALLATION . . � a ,SSACNUSEt This certifies that . . . .7. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . ... . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . ... : .: . .:' :`. . . . . . ..... . . . . . at . . . . . . . . . . . . . . , North Andover, Mass. Fee, Lic: No..: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer a� e� Building Location lP'j-J �Gf'fl�6/ ' Permit _ Owner's Na a -Cr�c Ll �("'�� -4 y New Renovation p Replacement Plana Submitted: Yeo E] No Q r, N U s c c A .+ w 0v z M t �' = a o P- C • el 1- TT z K O O = w of 0 " 14 .4 f 0 C O ~ ~ j ,K.t1 = K a r 0 1 ~ J w y �yy 46 D �. p J V > O 0 p OIIR—oaMtT. • !A*!MJENT tET FLOOn , 31x11 FLOOR t 31111FLOOR 4TH FLOOR aTH FLOOR l i ETH FLOOR , 7TH FLOOR t , ETH FLOOR Iflitdling Company NameCheck one: Certificate Addro3: _jD ✓ d /27 S 7 J Corp. —_ y d Partnership ✓-ems `�`vt. �---, l')� Business Telephone �1'E"!-i m/Co. _� (, U Z (� Nome of Lkensed Plumber or Das Fitter v d INSURANCE COVERAGE: have a current Ilablifty Insurance policy or Ile aubstanlial equivalent. Ye;ck M you have checked yes. please Indicate theo b type coverage by checking the appropriate box. A Ilablitty insurance policy 8"'. Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee doee nod have the Insurance coverage required Chapter 142 of the Mass. General Laws,.and that my signature on this q ed by txmnl! Application waives this requirement Check one: lure at Owner or Owner's ant Owner 0 Agent❑ I trsraby grllfy that all of he details and Information I have submitted tot entered)In abov Ilcallon ars true and rale to Ura bast of knOwiedge and that aft plumbing work and Inatallalions performed under the permN Isstrid r Iny PMthrenl provlsfons of the Massachuselis Stale pas Code and Chapter 142 of Um a&PPI Ion will In with alli T (Jcensa: Tit umber �— Uller Ona urs o rum of Or as at pyNiQwn Master Lkense►dumber �Journeymen APPROVED(orFICE USE ONLY) r., r x C' A hh III PERMIT NO. �/ // APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 I MAP NO. I LOT NO. 12 RECORD OF OWNERSHIP DATE BOOK iPAGE - ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING �Ir r OWNER'S NAMENO. OF STORIES SIZE 16 g OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST //} 2ND 3RD BUILDER'S NAMESPAN - - _ - v DISTANCE TO NEAREST BUILDING �"7"S� DIMENSIONS OF SILLS DISTANCE FROM STREET /V6 ' /_ POSTS DISTANCE FROM LOT LINES—SIDES �!� '�" REAR +, GIRDERS AREA OF LOT 7 FRONTAGE HEIGHT OF"FOUNDATION- Ll THICKNESS IS BUILDING NEW SIZE OF FOOTING /1 4 X /�/ , • o IS BUILDING ADDITION //� MATERIAL OF CHIMNEY _ "c � /�X //[ v ' IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND •S�e/1 P—��`, WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES of- EST. BLDG. COST 41/F-6-0 EST. BLDG. COST PER,SQ.SFT. PAGE 1 FILL OUT SECTIONS 1 - 3 - EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR c DAT FILED e BOARD OF HEALTH I NATURE OF OWNER OR AUTHORIZED AGENT F E E PLANNING BOARD PERMIT GRANTED q 7119 BOARD OF SELECTMEN xv BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY I I SFORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS, WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION E3 INTERIOR FINISH CONCRETE _ _ d l 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW'D PIERS PLASTER DRY WALL — UNFIN. - 3 BASEMENT 11 AREA FULL FIN. B'M'T' AREA _ '/, 1/7 �/ FIN..ATTIC AREA NO B'M'T - FIRE PLACES _ HEAD ROOM MODERN,KITCHEN, 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARMN D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR I_ BRICK ON FRAME l CONC. OR CINDER BLK. - STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ -- GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT 1 SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'•R OR VAPOR- - WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G , UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING c r Date._. -3.. . . .. . . NORT#y 3r �` TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION 5 �9SSAC MUSEtI( This certifies that . . �.'. . �. . . . >� . . : . . . . . . . . . . . . . . . . . . . has permission for gas installation . . f�?.J:. .l c .` . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . at �:2. !. . .�j''r�: '.f f . . . ., North Andover, Mass. Fee. . .A Lic. No.. S. A =/� =�. . . . . . . . f GAS INSPECTOR r Check# f _ J 6 -53 e MASSACHUSETTS UNNORM APPUCATON FOR PERAHr TO DO GAS fT11 G (Type or print) Date'' L 0 Z NORTH ANDOVER,MASSACH,U/SETTS Building Locations / / 0A G� �! 21 Permit# 6� Amount$ Owner's Name �j,�2, p"v k1c1 P C 1C- New Renovation Replacement Plans Submitted Ha SUB-BASEM ENT BASEMENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR R 4TH. FLOOR STH. FLOOR 6TH. FLOOR 7TH FLOOR 8TH. FLOOR (Print or type) one: Certificate Installing Company Name b�/`i ! G29�OLc � - l� Corp. Address �-b Pie Business Telephone 0irm/Co. . Name of Licensed Phunber or Gas Fitter INSURANCE COVERAGE Check one. I have a current liability Insurance policy or it's substantial equivalent. Yes [a Noo If you have checked M.please indicate the type coverage by checking the appropriate box Liability insurance policy D Other type of i xr mnity Bond 0 Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laves,and that my signature on this permit application waives this requirement. Check one. D Signature of.Owner or Owner's Agent Owner- ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plu nbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions ofthe Massachusea Statqtas Code anhapter l of the I Laws. By Signature officengtd.Plurnber Or Gas Fitter Title [--Plumber 3 City/Town 0 Gas Fitter License MG Master APPROVED(OFFICE USE ONLY) 0 Journeyman I i' i t fi f �3 3 Location No. Date y TOWN OF NORTH ANDOVER 9 { Certificate of Occupancy $ Eta' Building/Frame Permit Fee $ "`fly ' sw<Mus Foundation Permit Fee $ Other Permit Fee $ z` TOTAL Check # 17235 Building Inspect _ .- . e-• .. 3 I 1 r. D r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER.. DATE ISSUED: m a v ' SIGNATURE: AA Building Commissioner ctor of Buildings Date Z SECTION 1-SITE INFORMATION Q 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number W 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Disi;ic—t Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard. Side Yard Rear Yard Required Provide Required Provided Required Provided Q 1.7 Water SupplyM.G.L.C.40. 54) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private p Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 J SECTION 2-.PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record L ! & ec.kC,14.,j I a/ rdInP s.11 12d �C Name(Print) Address for Service Signature Telephone / 2.2 Owner of Record: Name Print Address for Service: O "y z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor' b , License Number Addres4,-- , / S ` 'J I Expirat`n Date 0K, Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 1"/,0E�) C ,-) Sf(Z'0C '" 00-) Company Name / 3 �.3 X11 Registration Number r... Address A AP 2,1(p I Expiration Date re Telephone SECTION 4-WORNERS COMPENSATION(NL G•L• C 152 § 25c(6)----1 Workers Compensation Insurance affidavit must be completed and subinitted with this application. Failure to provide this affidavit will e in the denial of the issuance of the buildin rmit. result Si • ed affidavit Attached Yes....... SE TION 5 ork Descri tion of Pro osed Wcheck all a Ucable NeF' Construction ❑ Existing Building ❑ Re it s � O ❑ Alterations(s) Addition ❑ Ac ssory Bldg. ❑ Demolition ❑ Other ❑ Specify BTi . Des of Proposed Work: �I !G .1q? f �� _ Z 40 �Ii SECTION 6-ESTIMATED CONSTRUCTION COSTS Item' Estimated Cos (Dollar)to beDIM 1 '¢ Completed b ermit a icant 1. uilding , e O (a) Building Permit Fee 2 �'ectrical 7 / 17S �' Multi lier (b) Estimated Total Cost of 3 1 Imbin Construction 4i chanical HVAC Building Permit fee(.)X_(b) 5 F` e Protection ( (� 6 T 1 1+Z+3+4+5 1 Check Number SECT N 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OW S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby uthorize -. My beh f if,ill all matters relative to work authorized by this building permit application, to act on Si natir of Owner SECTIO' 7b OWNER/AUTHORIZED AGENT DECLARATION Date i, ''hf E E• , property ,aAuthorized Agent of subject Hereby di Clare that the statements and information on the foregoing application and belie g g PP ahon are true and accurate,to the best of my knowledge 1 Prin i Si trebf er/A ent. Date NO. OF S ORIES SIZE BASENIE OR SLAB SIZE OF FLOOR TRyyMERS r9T2 Nu SPAN J 3 )IMENSId S OF SILLS )1MF.NSIQ S OF POSTS )IMENSIONS OF GIRDERS iEIGHT 01FOUNDATION THICKNESS IZE OF FC OTING X IATERLAL' OF CHEvINEY 3 B UILDII*t 3 ON SOLID OR FILLED LAND BUR,.DIN I CONNECTED TO NATURAL GAS LINE FORTH Town dover No. y C, o dover, Mass., y'� •� Oa► T O LAKE A. - T COCHICHEWICK ORATED U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System F u �00C ttA V BUILDING INSPECTOR THISCERTIFIES THAT..... t. .�............A.gAq..0!!........ ......................................................................... Foundation has permission to erect...j4*41W*(..... buildings on ....tal.......CA ... .��.�1..........�................ Rough to be occupied as..+.10 �.p r`.s1 �N6 `0V N � a y Chimney .... ....... ......... ................................................. ............................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By- ws relating to the Ins p ction, Alteration and Construction of Buildings in the Town of North Andover. ` 3 ` w PLUMBING INSPECTOR 4 (00 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMU EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS 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 RoughFinal No Lathing or Dry Niall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. v The Commonwealth of Massachusetts Department of Industrial Accidents office olinvestigations 600 Washingbton Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit location: Z� ty�'t.0� � �J[J city TIN�� ospe tzone# / I am a homeowner performing all work myself. �1 am a sole proprietor and have no one working in any capacity F1 I am an employer providing workers' compensation for my employees working on this job. comfy name. address: phone# msurince ca - policy# I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: coin gin.-name Address: city: phone# XX insurance co coni any name: address. cttvr -hone 9. insurance co pohcv# WiLI adddtti. al��}-_-e of ne�essar Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the its and penalties of perjury that the information provided above is true and correct. Signature q— Z 7-6 Date .Print name S ri Iu�.�h (� r .C$r�. .._.. .. _ . .. _.._ ._. ..._. Phone# C�c 7�, e in this area to be completed by city or town official w permit/license q_ -Building Department ❑Licensing Board s required Selectmen's Office oHealth Department phone#; -Other .'x_ _._.x'vi�_,r.,.._.�: "r:,.ad-., r .- F �PO1Ks.iatrc •- (revised 7/95 PIA) l J � ✓1LG U/O'rI?/rYCO'lZClIC2GU2 O�a///(�LOdCLCf2ll6P.�6 y'�: . BOARD OF BUILDING REGULATIONS . License CONSTRUCTION SUPERVISOR Number CS 0582415 �`` Bi+rtFidate X03/24/194,3 ' I Expires 03/24/2006 Tr.no- 21031 Re�tric"tetl 00 KENNETH B KEEN, i` 21 HEWITT N'ANDOVER, MA 01.845 Acting C mis ones [, J _ � � ✓�ie vomvnearuuP,a/� ��%�aaaac/u.�aeltb Board of Building Regulations and-Standards . HOME IMPR"O MMENT CONTRACTOR Reg stratin] 08383 expiration 8/1'872004 Type DBA i KEEN CONSTRUCTIONiCO. i Kenneth =Keen 21 Hewitt-Ave No Andover MA'018,4,5 Ad�roen�strator I�� ' ��I I I KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER,MA 01845 (978)691-5201 Fundeklian, Arthur& Lily 121 Campbell Rd. N. Andover, MA 01845 (978) 687-0618 Contract# 1614; Appendix A Date:4/25/04 Renovate& enlarge bathroom: • Demolish existing bathroom to studs • Remove wall between bathroom and bedroom • Build wall to accept tub, shower&dividing wall (approx. 10'6") • Remove linen closet&close door opening in hall • Supply& install one Harvey vinyl Classic Double hung new construction window over tub (approx. 26" x 39" with tempered glass) and repair exterior siding • Supply& install six 6-panel hollow core masonite door units with 2 %Z" colonial casing and new hardware • Supply&install blocking in walls for handicap grab rails around tub • Supply&install new underlayment flooring if necessary • Supply&install insulation and vapor barrier on all walls & ceiling • Supply&'install blueboard& skimcoat plaster( smooth walls, textured ceiling) • Supply & install trim on doors window and base to match existing • Supply& install Ceramic tile floor in bathroom($3.25/sq. ft. material allowance) • Paint walls, doors & trim(2 coat finish, 2 neutral colors) Electrical: • Update electrical to code in bathroom Supply& install fan/light combination with switching • Prep for vanity light • Supply& install four recessed light fixtures in ceiling switched on dimmers • Supply& install a GFI outlet near vanity& one outlet on opposite wall • Supply& install two exterior outlets(1 front, 1 rear) • Supply& install sub-panel if necessary • Wire whirlpool tub with heat Plumbing: • Supply& install.new 1" & 3/4" copper water piping in basement • Install customer supplied water softener and 50 gal. power vented water heater • Supply& install toe kick heater in bathroom 1 �G•.i�. -`fir KEEN CONSTRUCTION CO. f 21 HEWITT AVE. N. ANDOVER MA 01845 (978)691-5201 • Supply& install baseboard heat in bedroom • Install customer supplied fixtures in bathroom -a • Supply&install sprinkler head over boiler • Supply&install outside spigot Customer is responsible for supplying all plumbing fixtures including vanity, linen cabinet, Swanstone back splash around tub, Swanstone shower walls,mirror,towel rods, etc. Keen Construction is not responsible for cost of permit fees, changes required by inspector, plumbing fixe lyes, defective customer supplied materials,rotten or altered framing in bathroom area, closet doors or attic.fan. Customer may be responsible for additional labor if materials supplied to the contractors is defective or incomplete. Total Cost:$41,175.00 (forty one thousand one hundred seventy five dollars) Payment schedule:$1000.00 due upon signing contract $8000.00 due the first day of work $10,000.00 due when basement plumbing is updated $5000.00 due when bathroom is gutted $6000.00 due when bath is framed & rough electric is complete $5000.00 due when blueboard is hung $3000.00 due when room is plastered& doors are installed $3175.00 due at completion of contracted work Customer Kin th B. Keen ate Date 2 i �. 1614 KEEN CONSTRUCTION CO. PROPOSAL e 21 HEWITT AVENUE NORTH ANDOVER. MA 01845 _ All home improvement contractors and subcontractors Tel: (978)691-5201 engaged in home improvement contracting, unless Fax: (978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with Submitted -b j I �U n I the Commonwealth of Massachusetts. Inquiries about To: .... �.... �t ..... ___ I -- registration.and status should be made to the Director, .. `� _..__. . .......___ Home Improvement Contract Registration,One Ashburton Place, Room 1301, Boston, MA 02108 (617) 727-8598. ' ` Owners who secure their own construction related " "t permits or deal with unregistered contractors will be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE DATE REGISTRATION NO. F.I.D.NO- PH -1 -Z 5 - MA. H.I.C. 108383 04-325-8052 > C/S = Customer Supplied S + I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: — _ . ... .__ __- `K2�OU��e ......_-�... n — rriQw.._ �J�- 'l _. ._............... . .._ . See .Q ...._.......-------_._ ._..__.. ... ...... ..... _. --_.____ __.._... _.__.._._ ...............___. _.._.__..__.--...............___-. - ___ ____._.____ _.... ... ...... ..............___ _-_. -----_ ._._ _ -- - ___ _...................... . ..._. .....................-....--...... _----- _ .............._......___._________ ._............ _ > Construction related permits. -� -� .......................................................................................................•......___.............................,.-........................... .... ..... WORK SCHEDULE... ........................................................................................................................._.......................................................,....,................................................................................................,....,.....................,.................................................................. ............ Contracto-will n t begin t e work or order the materials before the third day following the signing of this Agreement,unless specified her toi w t actor will begin the work on or about (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by -v (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall comply with the requirements of this Agreement, In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of T`Q DU �� t`Q 1`iUnC e t-��-dollars($ L� D 5 Payment to be ma a as follows: % ($ ) upon signing Con ract; KENNETH B. KEEN Name of Contractor/Designated Registrant ($ )ton 21 HEWITT AVE. Street Address % , ) completion of N. ANDOVER, MA 01845 City/State $ ) shall be made forthwith upon (978) 691-5201 (978) 682-3231 ( completion-of work-under this-contract,-.-:- --=Phone Fax I Notice: No agreement for home improvement contracting work shall require a 1 i >down payment(advance deposit)of more than one-third of the total contract price Name n!s le in or the total amount of all deposits or payments which the contractor must make, in � l advance, to order and/or otherwise obtain delivery of special order materials and Authotzd jcfnature equipment,whichever amount IS greater. Note: This proposal may be withdrawn by us if not accepted within days. Acceptance Of Proposal -I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. DQ,,NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Si natur / 9rt '� F,�G Date Signature Date ! IMPORTANT INFORMATION ON.BACK OW- II . ti i