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Home My WebLink AboutMiscellaneous - 130 MARBLERIDGE ROAD 4/30/2018 (2) ... 130 MARBLERIDGE ROAD - - - _ -- �_. -� ---- 210/037��0 I. ` r I Location /3O MI' 11� /� P(d y No. 413 / Date 14ORTry TOWN OF NORTH ANDOVER f 1 �? •. AL o- ' Certificate of Occupancy $ 130 �VSAC11USEt Building/Frame Permit Fee $ ! Foundation Permit Fee $ Other Permit Fee $ f TOTAL $ �3y Check # ) / 3 8 /Iwo , 5 6 5 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: a SIGNATURE: a Building Commissioner for of uildings Date SECTION 1-SITE.INFORMATION e 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /�3 n til►3��2 c � �I r� 10 . Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District osed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard.''' Side Yard Rear Yard Required Provide red _ Provided Required Provided Flood ood Zone Information: 1.7 water supply M.G L..C.40. 34) 1. 1.8 sewerage Disposal System: Public 0 Private 0 Zone Outside Flood Zone. 0 Municipal 0 On Site Disposal System 0 _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT n 2.1 Owner of R�ecord * Name(Print) V Address for Service 7- 31EZ Signature Telephone 2.2 Owner of Record: Name Print Address for Service: I� Signature. Telephone R SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ 1111-Z414-af Z�fAIAIPAI Licensed Construction Supervisor. 015-0 z-8 / License Number 6th S/}LCA xlp, MT i Address r 108934 Expiration Date iSignatureTelephone .. 3.2 Registered Home Improvement Contractor Not Applicable ❑ Will r >I/�/�1✓fil/� r Company Name (�4—r J y, XP ��G�� 8 Registration Number J Address yl�� ` 7�r t�3 Expiration Date Si nature Tele hone i i SECTION 4-WORKERS COMPENSATION(AML. 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.......❑ No.......❑. SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Q Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS` Item Estimated Cost(Dollar)to be ' Completed by permit applicant 1. Building 2 O day r (a) Building Permit Fee Multiplier 4 2 Electrical (b) Estiiti'ated Total Co§t of O p . Construction-" r 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC /V C)/ 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 WELDING 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 tnie and accurate,-to the best of my knowledge and belief Print Name Si ature of Owner/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEMBERS iST 2 No 3 RD SPAN DR%4ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X . MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4 TOWN OF NORTH ANDOVER o� Norrv�q Office of the:Building Department �r b`-fun R ^�'°�°oma Community Development aad Senices 27 Charles Street North Andover,Massachusetts 01845 �4SggcHU D.Robert Rlicetta, Telephone(978)688-9545 Building Ceinurissioner FAX(978)688-9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit# the debris resulting from the work shall be disposed,of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at/in: (Site location) Signature of pe t pphcant Date Michael McGuire,Local Building Inspector James Decola,Electrical Inspector James Diozzi,Gas/Plumbing Inspector I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02191 Workers'Compensation Insurance Affidavit Please Print Name: Location: Glty Phone am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: AIX, T � J,,,/ �✓✓� Address 157,9-c-Irk /4f> City: Phone' f 7r Insura ce Co. P-0 I igy 4, Companv name: Address Ctty: Phone# Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the Imposition of criminal penalties.of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDI*R 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 herby certify under the pains and peneflies of perjury that the information provided above is true and correct ® a 0 Signature � Date,---' _13 –y 2– Print Print name Phone# -- Q Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other RM WORKMAN'S COMPENSATION ^a VkORTFj Town , of over No. Ll i _ _ �. o - o dower, Mass., 3-,a R�Ndk COCMICKEWICK %S RATED PV .7 BOARD OF HEALTH PERMIT T D . Food/Kitchen Septic System / BUILDING INSPECTOR THIS CERTIFIES THAT S � � � � 4 � PA Foundarion yhas permission to erect.....C;,..3.................... buildings on... ffi A....... .�I.� �.... Rough ;� (� D c Chimney to be occupied as.'fit.. IAC► '! . l� Z w....... �. UV y ............................... ................... ... . .. ..... . provided that the porson accepting this permit shall in every respectconform to the terms of the application o e in Final this office, and to the provisions of the Codes and Ls relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3nD7)0 A 30, � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PER,MTT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO ST TS 4C Rough ......... . . .. . . ............. ........Aft Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Celina5 5hdural �nqineerinq I. C Phone 978.465.6436 Daniel L. Gelinas, P.E. Fax 978.465.5160 579A North End Blvd. Salisbury, MA 01952-1738 email danlgelinas@comcast.net September 20, 2011 Mark Rae, Belford Construction Inc 283 Washington St Groveland MA 01834-1008 Subject: 130 Marbleridge Rd,N Dear Mr. Rae: Per your request I observed the framing modifications today for the addition at 130 Marbleridge Rd. Framing observed satisfies the requirements of the IRC 2009 as amended by the Massachusetts State Residential Code 8th Edition _ - i Please call with any questions Very Truly Yours, Daniel L. Gclmas, r.E E framing per IRC 2009 9-20-11 job 11116.doc �A os GEUNAS STM j, t�s�.3399* ' d Date.....l......................... f ,&ORT", 3?;•:�``°: "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ♦c�"'YYYY ��p��y a _ y SSACMUS� This certifies that ..... has permission to perform ..........:S 4n ...:' Common-wealth of Massachusetts Official Use Only Permit No. 16 V/2 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 amvebiak) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ,527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL rATFORWTION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to p 66* the electrical work described below. e7 Location(Street&Number) 1 -30 Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes LSI No ❑ (Check Appropriate Box) Purpose of Building Ar.�IA;41141 Utility Authorization No. E)ds6ng Service Amps Volts OverheadEj UndgrdF_1 No.of Meters New Service Amps Volts OverheadEl UndgrdF1 No.of Meters Njimbe'r of Feeders'and.Ampacity Location and Nature of Proposed Electrical Work: A--e A./1'ef-e Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle) ans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators ISA No.of Luminaires Swimming Pool Above o.of Emergency Ei—ghting -grnd. El 9rnd. 'El Battery Units No.of Receptacle Outlets No.of Oil BIJUrnerB F—OX.A.L.A.R.MilNo.of Zones No.of Switches No.of Gas Barimers No..of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number I Tons I.KVV.......... No.of Self-Contained Totals:I---- --j-- Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Connetion ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Beaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: 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.) Work to Start: /iZ 6 jInspections 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 covegrge is in force,and has exhibited proof of same to the pem-ift issuing office. CHECK ONE: INSURANCE J!T BOND F1 OTHER*E] (Specify:) lcetW is certify, under the and ofperjury,that the information on this application true and complete. FIRM NAME: SV(j1VAV eZ,4�/ YVJ_4'— ?4P17,0 / AlAll' LIC.NO.:, 9 4 Licensee: ///V--- Signature I /— LIC.NO.: 7 7_11 7P (1fapplicable,enter"exempt"in the license number line.) Bus.Tel.No.- Address: 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 required by law. By my signature below,I hereby waive this requirement. I am the(check one) [I owner []owner's agent. Owner/Anent I I The Commonwealth of Massachusetts 'El Department of Industrial Accidents Office of Investigations faIk V600 Washington Street .{�z - Boston, MA 02111 www.tixass gov/dia . Workers' Compensation Ins4ranee Affidavit: Builders/Contractors/Electricians/Plumbers Au>olicantInfn,.ro ion Please Print Le�bly Name (Business/Organization/individual): Address: City/State/Zip: Phone#: . Are you an employer?Check-the appropriate-box: ' I.❑ t,am•a em io er with 4: 7`W of project(required): P Y _______ ❑ 1 am a general contractor and I e..Moyees(full and/or parttime), have hired the sub-contractors 6' ❑Newconstructton 2.❑ I am.a.sole proprietor.or partner_ listed on the attached sheet,1 7• ❑Remodeling ship and.have no employees These su&contractors have 8. ❑Demolition' working forme in any capacity. workers' comp,insurance, i [No workers'comp,insurance 5. We 9• ❑Building addition P ❑ are a corporation an required.] rP d Its officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exeinption per MGL' I I.(]Plumbing repairs or additions myself,[No•workers'comp. c. t52, §I(4),'and we have no insurance•re aired. # 12.[]Roof repairs q ] .employees. [No workers' I3❑Other camp. insurancerequired.] Any applicant that checks bob#t must also fit'out the section below showing their workers'bompensation pelicy information. t Homeowners who submit this affidavit Indjctuing they M-a doing all work and then hire outside contractors must submit a new'Affidavit indicating such. - #Contractors that check this box mustettached an additional shdetshowing Lhe`nsne of the sub-cantractors and the;,sverka r'ten p,policy ir, ;,arcn t aa?an empdnyer!teat P5�YBai7?dafi�:we�s&ePa'c®as� er�seatao a as�saeatrPac_0f0,-my.employee: fed®iv is tdse policyaa�d job st¢e informado ' 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- r 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 n day against-the violator. Be advised that a copy of thisstatement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sienature:- Date: Phone#: Official use only, Do not w.rhe L"t.a is a:ea,to be campletedhy city or town ofjiciaL City or Town; Permit/License # Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town•Clerk 4,Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: P The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations 600 Washington Street Boston,AM 02111 yY www.mass govldia Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/Plumbers Applicant Information please Print Le ibly Name(Business/Organization/Individual):_�J�/j�a, 4A lm n/ 7' Address:_ I . City/State/Zip: J/ r� Phone#: 9 W [aa an employer?Check the appropriate box: p Type of project(required): a employer with / 4. ❑ I am a general contractor and I loyees(full and/or part-time).* have hired the sub-contractors6 ❑New construction a sole proprietor or partner- listed on the attached shget. t 7• Eg-K�em.odeling and have no employees These sub-contractors have8. ❑Demolition ing for me in any capacity. workers'comp,insurance.workers coin .insurance 5. 9• ❑Building addition p ❑ We are a corporation and itsired.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL11.❑Plumbingrepairs or additions lf [No workers' comp. c. 152, §1(4),and we have no ancere uired. 12•❑Roofrepairs q ] ' employees.[No workers comp,insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill 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 or myinfornation. emP toyees. Bel ow is tlae oticy andjob site i Insurance Company Name: 6r'o h 1--44 S44—C Policy#or Self-ins.Lic.M �✓ C '�� -71-) 37S-_5-3 7 � ' Expiration Date: �— Job Site Address: Z30 _A City/State/Zip: /L- 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 ofMGL 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 Wvestigations of the DIA for insurance coverage verification. ado Izereby certify under the ains a enalties o \ P fperjury that the inforralation provided above is true and correct. iinature: Date: 'hone#• 7� 8„Z �o Y 7 Official use only. Do not write in this area,to be completed by city or town official. City or Toxon: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town CIerk 4.Electric 6. Other al Inspector 5.Plumbing Inspector Contact Person: Db-u 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 apartinents 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 commonwealth buildings in the g for any applicant who has not produced acceptable evidence of compliance with the insuranc6 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,b checking the boxes Y g 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 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 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 referencd 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 re a home owner or citizen is obtaining a license orermit not related lated to an business or commercial i.e Y rcial venture ( .a dog license or permit to bum leaves s 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 C01--i uon-wea th- 01'x0'assac'oosetts Department of Industrial Accidents Office of Investigations 640 Washington Street Boston;MA 02111 Tol. # 7� 6� 7274900 est 446 or 1-877- MA.SSA,FE Revised 5-9.6-ns Fax#617-727-,7749 0369 Date... ......... .. ... .. .. .. TOWN OF NORTH ANDOVER 0 PERMIT .FOR WIRING CHUS This certifies..that .............. ............bb... ....... .. .. .............................. has permission to perform .......................................... wiring in the building of............................ ... v at.../.5457 ............. orth Andover,Mass. Fee...,�'635G Lic. .......... &7� �IC�L P c� AR [CAL INS R Check # Commonwealth of Massachusetts Official 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(MEC),5 7 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: 16 City or Town of: NORTH ANDOVER To the Inspdctol of Wires: � B this application the undersigned gives notice of his or her intention to perform the electrical work described below.Y PP Location Street&Number )�� Owner or Tenant fM,tl ( Jddz2ff &fnL Telephone No. Owner's Address a ✓ 11.,00 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Ut�ffltyhorization No. / 3Y 70-Existing Service 1GJ Amps / c> l yoVolts Overheadndgrd❑ No.of Meters New Service f Jt) Amps U 41Y& Volts Overhead❑ Undgrd�No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: �N L Com letion of the followin table may be waived by the Inspector of Wires. ddle c No.of Recessed Luminaires �� No.of Cefi:Susp.(Pa )Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Poo1 nd. ❑ rnd. ❑ Batte Units -- No.of Rece_ntacle Outlets No.of Oil Burners FIRE ALARMS JNo.of Zones No.of Switches No.of Gas Burners No.-of Detection and a Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Dis osers Heat Pump Number Tons J.KW No.of Self-Contained p Totals: Detection/Alertin Devices No.of Dishwashers f g S ace/Area Heating KW Local❑ Municipal E] Other P Connection No.of Dryers Heating Appliances KW Sec N o Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts. No.of Devices or E uivalent ons s No.Hydromassage Bathtubs No.of Motors Total HP Te1No of unicati 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.) Work 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 covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of peWry,that the information on this application is true and complete. FIRM NAME: U` LIC.NO.: Licensee: n!},4_2�,J&,--I Signature LIC.NO.: (If applicable,enter"exe t"in the license number line.) Bus.Tel.No.. Address: 5tli c�� 1 �u �''� �� Alt:Tel.No.: 6` a 5'ySS� *Per M.G.L c. 147,s. 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 required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent F��FEE. $ Signature Telephone No. The omzwfeanla of Massachusetts Departmustrial Accidents Office of Investigations 6yiton Street V/ 600 Washing a It ! Boston, MA 02111 t'1 www.nzass.gov/dia . Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers A licant Information Please Print LeQibl Name(Business/organizadon/Individual): �- - Address: LAj bG City/State/Zip:_ -dll " �f(��/ Phone#: . U QJ 6 �< Are you a employer?Check.the appropriate box: T ype 1.❑ h ' a employer with 4, ❑ I am a general contractor and I Tyof project(required): mployees(full and/or part-time).* have hired the sub-contractors 6 construction 2. I am.a.sole proprietor or partner- listed on the attached sheet.t �• ❑Remodeling ship and have no employees These sub-contractors have 8. Q Demoiitiom working for me.in any capacity, workers' comp.insurance. g, ❑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 I L❑ Plumbing repairs or additions myself.[No•workers'comp. c. 1.52, §1(4);and we have no 12.❑Roof repairs r insurance required.]t employees. [No workers' comp, insurance required_] 13.[.Other *Any applicant that checks bor#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 the., workers'temp.policy informadoa. t am an employer that is providing:worlters'compensation irasurance for my employees. Below information. is the policy and job site ' 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. I do hereby,certify e h ins and pe les er' at the information provided above is true and correct Signafor1e: L q Date: f Phone#: t) l �j d g — VS S Official use only. Do not write in this area,to be conp'eted 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#- 71 10 Date. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ;,SSAC14US c� This certifies that *1-- l��h. 00A��y�. . . . has permission to perform . .XeKo. 4 p! !! . . . . . . . . . . . . . . . . . . . plumbing in the buildings ofd. . .I.A4 . . 9 . . . . . . . . . . . . . . . . . . at. . ./Jo— North Andover, /Mass. Fee A.4 rS .Lic. No / c' fs r /!•,lam ,• . . . PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Sep 17 2011 Building Location 130 Marbleridge Rd Owners Name Rae Permit# Amount Type of Occupancy Res. New Renovation Xl Replacement Plans Submitted Yes No FIXTURES z o a S U xL 00 g O L W "" A A a C O O a Odq K SLBERff. &1gI IM 1 1 2 1S' RDM 2 1 3 1 1 1 M RDM 2 3 1 1 1 3M HDCR 41H RiOCR 5111 ROCR 6IH FU= 710[1 DOCK SII3 Him (Print or type) Check one: Certificate Installing Company Name Bomar Plumbing&Heating Corp. Address PO Box 694 Partner. Deny,NH 03038 Business Telephone 603-325-8958 Firm/Co. Name of Licensed Plumber: Robert Frazier Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity 0 Bond El Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted or ent in above applicatio�`are true and accurate to the best of my knowledge and that all plumbing work and installati e o e e t Issued for this application will be in compliance with all 7rtine t provisions the Massac to mb o h 1 General Laws. By: Igna e o kens er itle /?.// Type of Plumbing License itylTo13425 own (cense Iquinber Master Journeyman APPROVED(OFFICE USE ONLY El 7809 Date. . .� A.... ... . N°RSH °f �' TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SACHUSEt 06- o a This certifies that ./9" �. . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . .�C'n P.44;. . . . . . . . . . . in the buildings of . . . .1 t. .� 4 . . . . . . . . . . . . . . . . . . . . . . . . . at North dover, /ass. Fee. .. . . Lic. <Al ... . . . . . . . . . GASINSPECTOR Check# MASSACHUSUM UNN ORM APPLICATON FOR PERNIIT TO DO GAS FITTING (Type or print) Date Sep 17 2011 NORTH ANDOVER,MASSACHUSETTS Building Locations 130 Marbleridge Rd Permit# Amount$ Owner's Name Rae New❑ Renovation El Replacement ❑ Plans Submitted ❑ � w � w w a 94 M x a o ¢ o a z o Z w w d x � a j d w w a Ma w x w F x Z w > w z a e a 0 O z o w �a x o x w x 3 A a U x li c� a F o SUB-BASEMENT B A S E M ENT 2 1 IST. FLOOR 2ND. FLOOR 1 3RD. FLOOR 4TH. FLOOR 5TH . FLOOR 6TH . FLOOR 7TH. FLOOR 8TH . FLOOR (Print or type) heck one: Certificate Installing Company Name Bomar Plumbing&Heating Corp Address PO Box 694 Partner. Deny,NH 03038 Ilusiness Te ep one 603-325-8958 Finn/Co. � Name of Licensed Plumber or Gas Fitter Robert Frazier INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes X❑ No If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy X❑ Other type of indemnity ❑ Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 11 Agent 13 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 plumbing work and installations ed der Pe it Issued for this application will be in compliance with all pertinent provisions of the Massachus to ode d C r 142 of the Geral Laws. B Signature of LI n d Plumber Or Fitter By: Title X� Plumber 13425 Z lCity/T own Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) ❑ Journeyman