HomeMy WebLinkAboutMiscellaneous - 125 LYMAN ROAD 4/30/2018 125 LYMAN ROAD
210/031.0-0049-0000.0
�I
Date.. . !. . ��. ...
NORTH
pE
o� TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
SSACHus
This certifies that . . . ...
has permission for gas installation ( . . . . . . . . . . . . . . . . . .
in the buildings of . . �.'P U . . . .
at J `. . . Gf. l- P4. .1?� . . . . . . . . . ., North Andover, Mass.
Fee. :?�Q. - Lic. No. P.3.(9 . . A!
GAS INSPECTOR
Check#
6900
MASSA.(NUSUM UNWORMAPPLICA'I�ONFORPII T
TO DO(Type or print) GAS 'I'ING
NORTH ANDOVER, MASSACHUSETTS Date
Building Logations
Permit#
Owner's Name Amount$
New Renovation /-e
El Replacement Plans Submitted
u
w ,
0, a o u .
a m
rh
a W e W W o o c z
Z W E �• W C W f• 6``c1
w C d� L. �. W C7 p w W V x C
ra
SUB -BASEM ENT
S , > p < Z O z W "7
. BASEM
T. + ; O m a d p
1ST. FLOOR r
2N D . FLOOR
3RD . FLOOR
4TH . FLOOR
T . FLOOR
6TH . FLOOR
7TH . FLOOR.
8TH . FLOOR.
(I':int or type)
Nance C'neck Corp.
one: Certificate Installing Company
Address U bK —J 2 —
'v,—U ✓i—, d U 0-.e'L, � Partner.
m
usess 'e ep
irnVCo.
Name ofLicensed Plumber'or Gas Fitter
[INANCE COVERAGE
a current liability insumnce,policy or it's substantial equivalent, Check one:
have checked es please indicate the type coverage by cheelcin Yes
y insurance policy g the a ro nate box No�
Dp p
Other type of indemnity
Bond 13
s Insurance Waiver I am aware that the licensee does nd°es n— ot ve the Insurance cove
eneral Laws,and that my signature on this permit applicationwaives this requirement.rage required by Chapter 142 of thee of Owner or Owner's Agent Check one:
Ownerhereby certify that all of the details and information I have submitted(or entered)in er
D a glent13
best of my knowledge and that all plumbing work and in ions
compliance with all pertinent provisions of the Massac a ionsstatPerformed under Permit lssu d for this applicatiocation am true and n c���o the
as Code an apter.142 f the General
ws.
Title Signature of Licensed P umber Or Gas Fitter
tle Plumber /
City/Town L
Gas Fitter rj. .
icense um er
Master
APPROVED toce uss oNLri Journeyman
De art OJAlimachuseft
� r
f dustrtol
ROL. P n2elLt�D Ih �CCLdellifs
Dice o
f.Ircvesfigations
600 W
ashirzeoton Street
62111
Workers' Compensation l nsurance.A '-yrs°Oz'�d a
AD licant Information davit. $uwilders/Contractors/Electridians/Plumbers
Name (Business/br Please. Print Leailaly
g nizabon/individuai):
Address:
City/State/Zip:
Phone#
Are you an employer?Check the appropriate box;
l.❑ I
an a employer with
em to ees 4 ❑ I am a'erleml contractor and I Type of project(required);
P Y (full and/or part-time).* have hired the sub-contractors •6. ❑ New construction
?.❑ I am a sole proprietor or partner_ listed
ship and have no employees}o ens M the attached sheet.I 7. ❑ kemodeling
working forme in any capacity. These sub-contractors have .
work 8• E] Qemotition
[No workers' comp. insurance 5 El We ers comp. insurance,restored j are a corporation and its 9. ❑ $uiiding addifion
ofricers have ex I0:
9 3.❑ 1 an a horrreowner doing all work n of ex V excised.then ❑ Electrical rpaiis or additions
myself. [No.workers' comp. c. 1$2p�on p MC'L I l.❑ Plumbing r„
insurance required.] t 1�4)�and we have no P 6pairs or addirions
'employees. [No workers' 12,❑'Roof repairs
Any appficant.that checks box#I.must also fill out t}se section b o camp.otn5urg�ce required.j 13.❑Q f}1er
t iiomcowuets whc submit.this affidavit indicatiltg they are doing :Eve:.r ag th.-tr workers'com po cy infamlation,
1Conuactors Ihat Check this box.must pensation L ,
attached an additional sh '�`�`n ncrr cutsiae cuniraciurs must submit a new
eet showi ii in_:
T the neme of.the st:h-cam amury g scoh.
J attt Q11 etnpl[t}'er tfs�FS provi4gn. worke!s e.OF,�T.ePEe '-Matots and their work=,comp,Poli infannation.
imforma6mL f��L�si�FQllCe Ot f
.f m} enrploye_s. Below is the pofi,!y�job site
Insurance Company Name:
Policy#or Self ins. Lic.#:
Job Site Address: Expiration Qatr:
Attach a copy of the workers' compensation policy declaration Q / City/std_-Cip:
Failure to cure coverage as required under Section 23A of ode 1ShOWIRp the policy number and expiration date}.
fine up to 51,500.00 and/or one-year imprisonmetrt,as well MGL c. 152 can lmd to the imposition of criminal
of up to.5250.00 a da Q ' civil penalties in the form of a STOP WORK p�Ep and a fine
Y a�aurst the violator. Be advised that a copy of thisstatement ma
Investigations of.the DIA for insurance coverage verification,
be'forwarded to the `Office of
I do here6j,certify under the paint and pphn/fi�of perjur3,that the in or
Si--nature- f mafion provided above is true and correct
Phone#: Date:
Official use only. DO hot write in tats area, to be complersd.b,
J tidy or town ofcial
City or Towa:
Issuing Authority PermitfLicense;T
e rrf� (circle one]:
1. Board of Health 2. Building
e Department 3. CitylTav�rn
6. Other Clerk 4. Electrical lnspector S. Plumbing
b Inspector
Contact Person:
Phone#:
Jtu1Vl LLtaLIV11 .juu joist ucTionS
�4A
Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for thea employees.
Pursuant to this statute,an employee is defined.as"..�ve�, person in the service of another under any contract of hire
express or implied;oral or written."
kn 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.incluciing the legal representatives of a deceased employer,orthe
receiver or trustee of an individual,partnership,associati on or other legal entity,employing employees. However the
owner of a dwelling house.having not more than.three ap artments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maint=ance,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 anemployer."
MGL chapter 152, §25C(6)also states that"every state c►r local licensing agency shall withhold the issuanmor
renewal of a license or permitlo operate abusiness or- to coastmat buildingaT in the commonwealth for-any
applicant who has not produced acceptable evidence of compliance witb the insurance coverage required"
Additionally, MGL chapter 152, §25C(7) states"Neither the commonwcaith nor any of its political subdivisions shall
enter into any contract for the performance of pudic worj< until acceptable evidence of compliance with the insurance
requir=ents of•this chapter have been presented to the rAn g authority.".
Applicants
Please fill out the workers'compensation affidavit compkl-ete}y,by checking the boxes that apply to yora situation and,if
necessary,,supply sub-contractor(s)name(s), ad re
ss(es) grad phone number(s)along with their c-ertificate(s)of
insurance. Limited Liability Companies (LLC)or Limitacl 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-. r
employees, a policy is required. Be advised that this affiei,avif maybe submitted to.the Department of. Industrial
Accidents for confirmation of insurance coverage. Also ]be sure to sign and date the.afndavit. Theaffiidavitshouid
be returned to the,city or town that the application for the permit or license is being requested,nat the D„ aftmt of
Industrial Accidents• Should you.have air �estions res T op ,
-.ding the-lata or.if you are mquirrd to obtain a workers
compensation policy,please:all the Deparnnent at the nta-rnbcr:Iist.ed below. Self insured companies should enter their
self-insurance license number on tine appropriate line. .
City or Town Officials
P}ease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit foryou 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!}icense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given y=,need.only submit one affidavit indicating cun-erit
policy information(if necessary)and under"Job Site Address"the applicant should write"all all locations i
„ n c' or
town).-A co of the affidavit that has been official} (
PY } stamped or marked by the city or taws may be provided to the
applicant as proof that a valid affidavit is on file for future permits or Iicenses. A new affidavit must be filled out each
Y=. Where a home owner or citizen is obtaining a licens- or permit not related to any business or commercial venture-
(i.e. a dog license or permit to burnleaves 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, .
lease'do not hesitate to give us a call.
P �
.The Department's address,telephone and far, number.
The Commonwea_1th of Massachusetts
Department of Endustrial Accidents.
Office of 1:11vestigations
600 WashLi gton Street
Boston; MA 02111
T51. # 617-727-4900 ems-*406 or 1-877 MASSAFE
Revised 5-2545 Fax#61 7-?27-7749
VifUM-Maam.c ov/dia
I
I
Date.....
TOWN OF NORTH ANDOVER
,PERMIT FOR WIRING
S CHUS
This certifies that .............
..........................................................
ZINI`X
has permission to perform ......./.7 )./*Z�*"*/*"R.-I/...................................
wiring in the building of.............61...... ......................................
at..... ......4y. .,,w1#.v....Ati...............I 6h,h.Andover,Mass.
Fee... Lic.No#11 ................ ... .... ... .
ELEcrR CAL INSPECTOR
Check
8362
%~406886yisrrG�ifGff tJf lRitrS.ldiG/1i/$elI5i k.miciai kise(►ni\
Department of Fire Services Permit No.
Occupancy and hee Checked
." BOARD OF FiRE PREVENTION REGULATIONS
t#c<nc blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All kNork to he pcxliirmcd in accordance 4vith the.tilassachuscits Electrical Code(NIFIC'). 527 c%—IR 12.00
(PLE.I,yE 1'RhVT LV IjVK OR TYPE ALL L*vl' )R114710,V) Date: ?'-- IK- ,-1
City or "Town of: vy� To the- Irl.p ctor of l-'�jre,v:
I3y this appiication the unders;gned gives notice at his or her intention to perfct , the electrical work described below.
Location (Street& ;Number)_f Z — 4 ��
Owner or Tenant .—� .y G Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes No
❑ (Check Appropriate Box)
Purpose of f3atilding_— `� .
Utility Authorization No.
Service Zc-,p Amps Jad / Z-9Ll/Volts ❑Overhead tJttd rd No. of Meters
g
New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: c � ,) ,�i�g �_ �s�'�•,��
C ant ilrrrnrt of rhe•/nitu}ctrrg tnhl<t ntur hc�waived hr the of It 7rc,
No. of Recessed LuminairesNo. of Ceil.-Susp.(Paddle) Fans o. o " ota
Transformers KVA
No. of luminaire Outlets No.of liot Tubs Generators KVA
No. of l.,uminaires Swimming Pool Above ❑ n- EJ 0.o niergencv rg Ing
rnd. rnd. Hatter ()nits
No. of Receptacle Outlets 229/ No. of Oil Burners ZFIRE ALARMS ��Zot
No. of Switches d No.of Gas Burners .o etectron�an
Total lniti3tinp Devices
No. of Ran0cs- No. of Air Cond. ions No.of Alerting Devices
No. of Waste Disposers eat temp um er ons JKW INO.o Net - 'ontained
Totals: I Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW L(mal❑ unrcipaI [I Other
No. of Dryers Heating Appliances KW Security Systems:
No.o. o Ater
No.of bevices or E, uivafent
1#eaters KW o.o (>. o Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No. Hydromassage Bathtubs No.of Motors Total HP elecommunicatrons 'ra
ng:
OTHER: No.of Devices or Equivalent
tltru'h tuh/iriunul,/ctui/1/tk'sH'ccl. or its required hi'I/ti'htspcc'ror o/ 11 iiv.v
IAlin,ated Value of Electrical Work: (When required by municipal policy.)
Work to Start._f Jp�l ntipecttolls to be requested in accordance with MEC Rule IQ.and upon cornplet;on.
INSURANCE COVERAGE- Unless waived by the owner, no permit fin the performance of electrical \%ork may issue unles
1 (Ile licensee provides prop fof liabilit , insurance including
'completed uperation'�a>vera`�c or its suhstantiai equivalent. hlie
undersigned ecitilics that suet,covera� n tierce, and hal exhibited proal of same to the permit isatin- office.
CIIFCK ()N[:-. iNSURANC1.. BOND ❑ (}_fliI,R ❑ (Specify')
/c•ertift, miler the pains urrd penn/ties ofperjttrt>,that the hifbrntation net this upp/icotion is trite and canttp/ete.
F112`7 NAME: . �.+, L/ , ems- LIC'. NO.: `� y
Licensee: ., ,r `f Signature LIC. NO.: P 3 3
l/iq�taii�rl�h, rr� r "tu•nit!t' int rhe(i�'i�r,�� ttttnrhrr lirrc.i Bus.
Address: ti
Vh�0770t. Tel. No.:
Secur its SN acro Contractor License required For this work- if a pliable,enter the license number here:
OWNER'S INSURANCE WAIVER: i an,aware that the i.icensee docs rrrtt have the liab;hty Insurance coverage norinaliv
required lay law. BY my siumature below, I hereby waive this requirement. I am the(check rine)[] rnvncr [; owner's agent.
Owner/Agent
Signature �_ Telephone No. PF_RN-11T FEE: S
Z 3-�
M'
a
Date.
�TM�tia TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
40
,SSACMUS�This certifies that .,e1/l . ?�J""`�'/. . .
has permission to perform
plumbing in the buildings of . . .. .6.rvr ". :17. . . . . . . . . . .
at . �yh?.�i.I'1. . .,5�"r. . . . . . . . . . , North Andover, Mass.
Feef . . . . .Lic. o.
PLUMBING INSPECTOR
Check #
7843
.� "MASSACHUSETTS UNIFORM APPLICATION FOR PFRMTT TO DO PLUMBING
t?rW a T ((�� \
01
"�- Mus 7
talc=Jv Peri #
BulEdlv LoationJZ5 . LYMA-oc a Owner's M1mcGG0 c- --16 y
Type d.Octupa &S
New O encysuon RePtacetnerzt ❑ Ptans Saba&ed: Ya O No ❑
FIXTURES
z a
z Y -K
h h J a O ZF' W
2 N < C G S h Z Oz a C
a
U w y Y < a W = a z h
V c o a } < f.. p i c a p t x
= 0 7 t W C 3 [ W c K 0 _ ¢ a4< 0
W Z h h yW 3
. 0O 3
LL xC
Waa )e ao le
> O z z � o 4L)< <
K J J <i ¢ ¢ aC K O <� d
. � O •C � c o O
SUB—BSMT.
BASEMENT
IST FLOOR
2ND FLOOR
3RD FLOOR
ATM FLOOR
STK FLOOR
ETKFLOOR
7TH FLOOR
aTK FL00R
I nzt&Nlr�g any Nar� L e'lz Cheek on.c Cert e
Address
o(vQ ❑
8Lmi ss TcicphorK A w ❑ Firrr>JCo.
Mime Of Licensed P1 ,t, �T�-�- �{L •
INSURANCE COVERAGE:
brut s li N ty kuurznce pol cy or as sL�a-r`sal equivalent wh:� meets the reqs'ia rcrtLs of MGL Ctt 142.
YT `�— No ❑
t' you bout ehcdctd yam. please knd;catc the type CoYcragc by &,cx W the appropriate b-ox
A Wbj,-ty tnsurance policy ❑ Other type of k)demn2,y ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware tie trte licensee dots W have the in sura ct coverage mqu red by
CtaPter 142 Of ttx Mass. General Laws, and t' e rry signature On this Perrot; &PP6caUon wz}r-s the r�
C#xck orr_:
tune OILMTW t Owner ❑ Ate! ❑
or O++rr�er's
I Nvib'oertity that 4 of the details snd info=tm I ha-ee subr ',,*d kx ?in
wedge and that apkxnbir�work grid insiL)la om»d aid �'c*50n scants to t A bled Of my
PatjWt Prorisrons Of the Slate 14er P nit 2 of the for this Min ar,ce w 0
1"rk gru.ure o .ber .
Qty/Tovm
Type O' �+ Jocnrteyrrun ❑
I u F+ mbr' / / —75
}
Y
60 '15
oS-
Date..... `...� �..
r
`r NORTI{
'°�4, TOWN OF NORTH ANDOVER
3? ern. ...a •• °L
PERMIT FOR WIRING
Ss
ACMU
S
This certifies that ....... eL........ T
........................................
has permission to perform ............. ........By/ .! ........
�� c
wiring in the building of...........+ ................. / t.�..................
at..........�.�.......... ........................�............ .... ,North Andover,Mass.
Fee7q"''-... Lic.No. ...... ..............................tet .....
ELECTRICAL INSPECT OR
I 7—
Check #
DrFD411BNF1 TOFP(1BIJCSAPMY
BQ4RDOFFMP�REGULA? O527(dR l
Occup ncyNet Checked
APPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK
Am wORK TO BE PERFORMED IN ACCORDANCE wrrH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00. �
(PLEASE PRINT 1N INK OR TYPE ALL INFORMATION) Abate_CJ
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location(Street d:Number)
Owner or Tenant - ('e✓ ,2
Owner's Address
Is this permit in conjunction with a building permit: Yes E3No l/ (Check Appropriate Box)
purpose of Building T 1:fP /10,All r Utility Authorization No.Y=,=
Existing Service Amps
.Volts Overhead r7lUnderground No.of Meters
New Service Qff 62 Amps f J olts Overhead ®j'Underground C No.of Meters J
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No.of Lighting Outleh No.of Ha Tube No.of Tranatonnora Total
KVA
Na of Ligbdng Rxtnta Swimming Pooh Above Below Oenaaton KVA
ground mtd
No.of Receptacle Outlet No.of Oil Burnen No.of Emergency Lighting Battery Units
No.of Switch Outlets
No.of On Bwrare
No,of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones
Tom
No.of Disposals No.of Heat Total Total No.of Detection and
Pumps Tom Kw Initiating Device.
No.of Dishwuhen Space Ana Heating KW Na of Sounding Device
Na of Self Contained
Detactiorisoonding Devices
No.of Dryen Heating Devices Kw Loal 0 Municipal maw
Comrecdom
No.of water Heaton KW No.of No.of
SIVA Baihuis
No.Hydro Manage Tuba No.of Moton Total HP
OTHER'
t
,r
,. )nstaataeCo�Ptr®8tbdtra�}iarr�d•Maread>t80Guma1L8WB
rlha eactzWL eWhstmroeFbkircidr CM#E—* YE a NO
IhmezfntlbdverdpoafafsamebheOltiZ Y$4IfyouhmededYBS,pis�it�eQretypeafoo�ea�by
EdnabdvalredEhctdcal Wt&$
WadclDSw Reid Rao Are1
5gWundir et rPhVX sscf
FRMMNAW .� , r '�r "�� �� a r�oa�aeNo� R'StiTle
Lam
P/ Lict��Y l`TDl�2� /� Lioen9eNo /. �531.7�
&&agTdNa 2n2
•� OWMR'SIIVSURAt�EWA1VQt;IamawatedletlkLiamee tothglhei�uaioCoana�txkaat�arrialegiivaiata�is�iadbl+Massach�C�alaalLews
ardlhetmysigr�iaemdrsptsrritappk�IvraiKsOrsiagtierrlot
.� (Please check one) Owner � Agent a
Telephone No. —....PERMIT FEE S
kation z
No 17 V,3 Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
57ZI
14 Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
i .
Check # Ca?
8'2" 7 6
Building Inspector
a.
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVA OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Saolloo ow
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: IgNt
Building Colnmissioner/IRELWor of Buildings Date Z
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assmms Map and Parcel Number:
.31
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: /�l
Zoning District Proposed Use Lot Area Fronts fl
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
ReqWmd Provide ReqWmdProvi&d ReqWred Provided
1.7 Water SupplyM.GL.C.40. 34) 1.3. Flood Zone Into : 1.8 Sew=W D6posd System:
Public 0 Private 0 ze Oarside Flood Zane 0 Municipal ❑ On Site Disposal System 0
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT , (•!O
2.1 Owner of Record
Name(Print) V Address for Service
9 ' o
rgnature V Telephone
2.2 Owner of Record:
C
Name Print Address for Service: za
M
Signature Telephone
'SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Q. 6 Q
Licensed Construction Supervisor. VAI
License Number
Add c.�
�/7 9
. l
Expiration ate.
gneture Telephone r"a
3.2 Registered Home Improvement Contractor Not Applicable ❑
'Company Npe
::57&7Y f�� / " �IVT �T Registration Number rw
Address / /
So Expi , »ate Gy
Signa. re Telephone
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.......❑
SECTION 5 Description of Proposed Workcheck at a bk
New Construction 0 Existing Building ❑ . Repair(s) ❑ Alterations(s) ❑ Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
c>
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Completed bypermit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) -Estimated Total Cost of C
Construction J^�
3 Plumbing Building Permit fee(a)x(b)
4 Mechanical HVAC
5 Fire Protection
6 Total (1+2+3+4+5) Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• as Owner/Authorized Agent of subject property
Hereby authorize
to act on
My behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
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
r
Print Name
Signature of Owner/Agent Date
NO.OF STORIES SIZE
BASENIENT OR SLAB
SIZE OF FLOOR TIMBERS 1 S72' RD
3
SPAN
DM ENSIONS OF SILLS
DIMENSIONS OF POSTS
DAVIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS t
SIZE OF F0OTlNG X
MATERIAL OF CHRvlNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Proposal
PARAMOUNT
VINYL SIDING & CARPENTRY 7 School Street
MA LIC#056858 Methuen, MA 01844
Reg#108659 (978) 794-9950
PRO POL SUBMITTED TO PHONE DATE
o
STREET JOB NAME
CITY, STATE
AND ZIP CODE � y JOB LOCATION
0 V
ARCHITECT DATE OF PLANS ' JOB PHONE
We hereby submit specifications and estimates for: R
7-1
4JI�R , N7- XO or-- E-
�5'y1i�r - r -�C'Lf �T S
ro
�. �'� ���/� C�� � ,�'�.� ���,� r��SCS`>-✓r'N' � �I
' 0 o —/ 0 Vie=
�e�larlt�
It shall be the obligation of the contractor to obtain all permits as the owner's agent;owners who secure their own construction-related permits or
deal with unregistered contractors will be excluded from access to the guaranty fund.
Paymedollars($
nt to be made as follows: 0� �. /
!tL
krC-,Y Ci e
oN o
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices.Any alteration or deviation from above specifica- Authorized
tions involving extra costs will be executed only upon written orders,and will become an Signature
extra charge over and above the estimate.All agreements contingent upon strikes,accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days.
Arre nrp at f rop sal—The above prices, specifications DO NOT SIGN THIS CONTRACT IF
and conditions are satisfactory and are hereby accepted. You are authorized F�E�ARE NY BLANK SPACES
to do the work as specified.Payment will be made as outlined above.
Date of Acceptance: (�I? f Gy Signature
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
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
The debris will be disposed of in:
(51ZZ A ' /Z/
(Location of Facility)
na re of P rm't Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
NORTH
if-
Townof � _ 4Andover t
No. o .::A q 0
7413
SIP o - �A E dower, MasS.,
-wy COC MICMEWICK
I y
�S RATED
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
^� ,� �i ^ ! BUILDING INSPECTOR
THISCERTIFIES THAT...........COA........... .............................. ............................................................. Foundation
has permission to erect..... . ... ........ buildings on .....1 ....... .. N........0 ....,....... Rough
to be occupied as........... ....R!f r..O.... .......... ,S./601140V C. .............................................. -Chimney
provided that the person accepting this permit shall In every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws rel3 g to t Inspection, Alteration and Construction of
Buildings in the Town of North Andover. / Y� PLUMBING INSPEC'T'OR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION SCAR S ; Rough
.................. Service
......... ................................................
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
�= Boston,MA 02111
�,M 5�• www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ��'rl '"' v�t��� J�'��� �`�✓ A<
�
'Cyl-Vo
Address: � �
City/State/Zip: 14'���alv 4� Phone#.: 9 7G 7 2,� 6
Are you an employer?Check the appropriate box: Type of project(required):
to er with 4. ❑ I am a general contractor and I
1. I am a e 6. New construction
❑ employer ❑ e co stru
to ees full and/or part-time).** have hired the sub-contractors
Y ( P ) 7. Remodeling
2. 1 am a sole proprietor or partner- listed on the attached sheet. t ❑
ship and have no employees
These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance. 9
y P tY• E] Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.El Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work right of exemptionper MGL 11.❑ Plumbin repairsairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information'
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copyof 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 unprisonment, 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 nd the pains pen Ities of perjury that the information provided ab ve is tr a and correct:
Signature: Date: l0
Phone#: G / 9
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 M
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 all 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 permittlicense 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
r town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts =`
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia