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Miscellaneous - 14 WALNUT AVENUE 4/30/2018
0/1 Date ..��/ 0// Y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING fft�,,.J.e— Z 4 / 'SR— A 61 191411 ........... .......................................... �/ ....................................... has permission to perform Q .......... ........... A-�? ................................. perform. ..... .. ...... .. ....... .... I ......... plumbing in the buildings of.. ...................................................... at .......... / X .......6,", i .................................................................. North Andover, Mass. Fee .40 .. . ..... Lic. No. Y..U...3. ..... PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY . i MA DATE Q / , ( PERMIT # JOBSITE ADDRESS ����/� . _ OWNER'S NAME p _ P OWNER ADDRESS l/ 1 TEL - FAX { TYPE OR — OCCUPANCY TYPE COMMERCIAL F EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: FI!. RENOVATION: F! REPLACEMENT: PLANS SUBMITTED: YES ®I NOF FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS(OILISAND SYSTEM DEDICATED GREASE SYSTEM _f _.___.I �, ! __..___! —_.--( .-_.__f f _._._._._{ E I -------I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER_._.._i J ......_._ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK-- LAVATORY ROOF DRAIN-_i ... --_I SHOWER STALL SERVICE! MOP SINK TOILET URINAL WASWiNG MACHINE CONNECTION i WATER HEATER ALL TYPES WATER PIPING OTHER i — _ 4 IF s � ! INSURANCE COVERAGE: I have liability insurance its 'NO a current policy or substantial equivalent which meets the requirements of MGL Ch.142. YES 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia with all Pertinent provis' of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _..._ _ —_i LICENSE # SIGNATURE MP lid JP[] CORPORATION . , # PARTNERSHIP# COMPANY NAME ;jj���dyfd�, _DRESS CITY STATE ZIP TEL $ - FAXCi ELL ,EMAIL Q _ ot�eY ... ISl�1�?th- Q -- - -- ._ .�'►��t,�� . _.. - - -- ---------._....-._.. ---- --_+ O o N ❑ LU CL Cd w LL The Coinmonwealth of Massachusetts Department ofIndustrial Ari cidents Office of Invesiigations kv 600 Washington Street Boston, AM 02111 w3'VWunasag ovli is Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Aouiicant Information Please Print +Led%ly Name (Business/orgmiizationiindividual): �,��� 4elz) Address: City/State/Zip: ����/1%%f - DI�� Phone #: Areyou an employer? Check the appropriate bow Type of project (required): 1. [I am a employer with 'S 4. Q I am a general contractor and I 5. [I New construction employees (full and/or part-time).* have hired the sub -cofactors Z, Q I am a. sole proprietor or partner- listed on the attached sheet t 7. Q Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition worldng for me in any capacity. msmance workers' comp. insurance. 5. Q 'fie -arse cceporatim its 9. [l Building addition [No avorlM& camp required.] -e and officers have exercised their 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.5Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 1 2,Q Roof repairs inct►rance required_] t employees- [No workers' 13.Q Other comp. insurance required:] -Any kca t � ch=:•s box -#I Mns aso iii a, r ice s=:-tim � S^Ott'Lb r• -*s' .. ,,-nc clan qt y jf =..,jM T Bomeowntas who submit fais aindavit indicating they ate doing all work and -&ea hire outside contractors most submit a new affidavit indicating such. $Contractors that check this box must atfacbed an aMdonaI shei showing tim name ofthe sab-contractors andtheir woik=z comp mousy information Iam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site information. h=ance Company Name: (Z//-Cp6'/r Policy =; or Self -ins. Lic. Y �` �D lJ`�v��0 Expiration Date:. Job Site Address: �� Lejfz&/`%mel City/SiatAHp: Attach a copy of the workers' compensation policy declaration page (showing the policy numbbr 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 51.500.00 and/or one year imprisoimmM 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 immrance- mverage, ve+ificanon. I do hereby certify the paras and penalfies pe ' that the information provided above is true and correct . Simature: zor J� Date: O'jTwfid use only. Dlo not write in this area, fu-beaorapieted by city or town ojq!ciai City or Town: PermiVUcense # 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 anL d histruct.on s Massachusetts General Laws chapter 152 requires all employers m provide workers' compensation for $heir employees. Pursuant to this statute, an employeels defined as "...everype raondn the service of another under any contract ofhire, express or implied, oral or.written." An employer is defined as "an iadividual, partnership, association, corporation or. otherlegal entity, or any two or more of the foregoing engaged in a joint enterprise, and including flat legal representatives of a deceased employer, or the receivmr or trustee of an individual, pmtmsbip, association or other legal entity, employing employees. However the owner of a dwelling house having not more tine twee apartmLents and who resides tlierrmn, or the occupant of the dwelling house of another who employs persons to :do maiabemance, construction or repair work on such dwelling house or on the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer." • MGL chapter 132,§BC(6) also states that "every state or local licensing 'agency shaII withhold the issuamce or renewal of a licenseer permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of commprumce with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neifluer the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work umtff acceptable evidence of compliance with tie ins_ orance requirements of this chapterhave been presented to the contracting authority." Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supplysub-contrackor(s) name(s), addresses) andphone numbers) along with their certificate(s) of msaraace. 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 19 this affidavit may be submitted to the Department of lndnstrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the afiidavIL The affidavit should be retied to the oi�y or town the the application fur the Pmmiroi license is beiing:equestrd, neat the Departm t of Industial Accidents. would you have any questions regmduxg the law or if you are required to .obtain a worlaers' 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 Spat the afndavit 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 pemmitlricense number which will be -used as a reference number. In additions 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 shouted write "all locations in (city or town): ' A copy of the affidavit tsat has been officially stamped or marked by the city or town may be provided to the applicant as proof tint a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Vere a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture (Le. a dog license or pe unit to bum leaves etc.) said person is NOT required to complete this affidavit. _ The Of ofInvestigations would Ince to ihqvk you in advance for your cooperation and should you have any questions, pleas do nothesitate to eve us a call. The Department's address, telephone and fax number. The Commonwealth of Massachust�tts Depattanent: of 1ndtsisl Accidents Oface of hWftq -2fi8 s - 6W Washington st =t Boston, MA 02111 TeL * 617-727-49DO-a t 406 or 147' MiASSAFE Revised 5-26-05 Fax #r 61'7-727-7749 wwwmam-govfclia OP ID: COHA �iC�OC O CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 10/28/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemengs . PRODUCER Phone: 978-688-6921 Macdonald & Pangione Insurance P.O. Box 428 Fax: 978.6884350 NAME"cr Hannah Courtemanche AAI CISR PHONEFAX Arc No Ext :978-688-6921 AIC.No): 978-688-5350 104 Main Street North Andover, MA 01845 CraigS Childs E-MAIL ADDRESS: hannah@Mpins.net PRODUCER ANDOV-7 CUSTOMER ID #: INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE S 1,000,00 INSURED Andover Plumbing Heating Co MA Box Andover, AnM INSURERA:UtiCa Mutual Insurance Co iNsuRm B: Safety Insurance Company39454 INSURER C : 4481325 INSURER D: 10/26115 - INSURER E: MED EXP (Any one person) $ 10,00 TNSURERF I INSURERF UUVtKAUt8 CERTIFICATE NIIMRFR• oelnernM \n 1RA0=0. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE ROOL SUBR POLICY NUMBER POLICY EFF MWD POLICY EXP MMIDD LIMITS GENERAL UA80.1TY EACH OCCURRENCE S 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 4481325 10/26/14 10/26115 DAMAGE GTO RENTED PREMISES Eaoccurrence$ 50,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY S 1,000,00 GENERAL AGGREGATE $ 2,000,00 GE N'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMPIOP AGG $ 2,000,00 5 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) S 1,000,00 BODILY INJURY (Per person) S ALL OWNEDAUTO$ BODILY INJURY (Per accident) S B X SCHEDULED AUTOS 6230887 10/26/14 10/26/15 PROPERTY DAMAGE (Peraccident) S X HIREDAUTOS X NON -OWNED AUTOS Collision S 50 Comprehensive $ 50 X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,00 A EXCESS LIAB CLAIMS -MADE CULP 448141 10/26114 10/26/15 AGGREGATE S 2,000,00 DEDUCTIBLE S S RETENTION S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED7 N I A 4481326 10/26/14 10/26/15 WCSTAN X OTH- LI I ER E.L EACH ACCIDENT S 500,00 E.L. DISEASE -EA EMPLOYE S 500,00 (Mandatory in NH) II yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Plumbing and Heating contractor. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Plumbing 8r Gas Inspector Building Dept AUTHOR¢EDREPRESENTATIVE 1600 Osgood St Bldg 20 #2-36 North Andover, MA 01845 "�1f fa ©1988-2009 ACORD CORPORATION_ All riahts resPrvPd ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD SSUES REQ STE ""` PLUMB ER*S'77" is?i5E ITTI~RS_:; U ISSUES Tl 'f FOLLOWIN `:Lfi w -SE ` LJ_CENSED' AS A MASTER PLUMBER''`.:; > .w<• w a SSUES REQ STE ""` PLUMB ER*S'77" is?i5E ITTI~RS_:; U ISSUES Tl 'f FOLLOWIN `:Lfi w -SE ` LJ_CENSED' AS A MASTER PLUMBER''`.:; > .w<• a GEORG-E R LAROS E`..- Z . M`ITTtit1EN MA 01844-4234: = '> :`'< :0%0l / 7.6..:: ,-..:. >.< 3429 9983 22 ....... :to -...::. JAM, I itis •5r, . -<.� �•1 •0 . 81 1.1 :COMMONWE4LTH OF MASSACHUSETTS. <4 :L FASF ITT ERS FAS PtUMBERSBaI' i� , ISSUES THE FOLLOWI;l„.Lf,CENSE__-:_>::; CtGEMSED `k5 A"JOURf�EYMAN PLUMBER ry GEORGE R LAROSE --' .: >` Y44 001 Mf: t#[FEiV MA <01M1844 -4z.3`';-_ 1825 05/01/16 223428 ti` � U Cwj1: n,�'.'�� • �.i): i;O ...a=ilai„a�... J/�• Date .....J..!/....4., .L../ ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that � do ✓2, /i/ ...................... has percussion for gas i 't 11 lion. ......�......... hfrt in the buildings of ....... �� c "� ......................................................................................................... at ........ 1..:�t .........�r! I�� ...... ..................... North Andover, Mass. Fee4........... Lic. No..3........ N! ................................................. /77� GAS INSPECTOR Check # :'675 ?b 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY/t/ 0 MA DATE D PERMIT #�(PICO& JOBSITE ADDRESSI !� /�i�L'!�OWNER'SNAME G OWNER ADDRESS U !/ TELF_ TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: F— RENOVATION: DI REPLACEMENT: 09/" PLANS SUBMITTED: YES Q NO Q APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i __ 1 ! I BOOSTER ____� (� CONVERSION BURNER I COOK STOVE I— . DIRECT VENT HEATER I _ DRYER �� ( _ 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE -- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST I !_� —J lr-� J I __— I �. _ I I .__� _�. i I J --i I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER { ! _ I __—I i 1 I ({ I _ 1 f - I -- 1- - _ 1 [--! OTHER INSURANCE COVERAGE 1 have a current liabilijy nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES _ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[( OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and ccue to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent proviso Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y-,W— PLUMBER-GASFITTER NAME a.G__- LICENSE# _ _ .. 3 SIGNATURE — MP M MGF 0 JP (-j JGF FIJ LPGI D CORPORATION�#/[a PARTNERSHIPj(# LLC 0-1#= 't COMPANY NAMEDDRESS p�d/� iFal- /J CITY%� _ _ _ --� STATE i' ZIP TEL FAX - CELL 7? JEMAIL dmlb' a i • Ca __ __ 1 on Z N ❑ w w f C-` M The Commonwealth of Massachusetts Department ofgmdustrid Accidents Ll Office of Invesiigaiions 6.00 Washington Street Boston, 1194 02111 www.fncass govh a Workers' Compensation Insurance Affidavit: Builders/Contractors/El ectricians/Plumbers Applicant Information Please Prilat Le�ibi�r Name (Businessio g mzatonandmdval): yo/vol %O1� City/State/Zip: Phone #: Are on an employer? Check the appropriate box: 1. lama employer with J'� 4. ❑ I am a general contractor and I employees (fall and/orpart time) * have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. f No wmimscomp ince S. ❑ We-mr-a cmporati(m and its required.] officers have exercised their .3 ❑ 1 am a homeowner doing all wo�tic right of exemption per MGL myself. [No workers' comp. c.152, § 1(4), and we have no inmrance required.] t employees. [No workers' c9mp. Insurance required-] Type of project (required): 6. ❑ New constriction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs oradditions 11. [Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other R_=y ap +hc°at 1 -Met cheak box -41 must also uL of-Atcc swbon -a— <^o,.j +n --L g•• •L••y 7.�; v� �� }�0.. inIt)naECxl. T'riomeowners who submit ars aiiidaait indicafmg they are doing all work aad aea hue outside contractors must submit a new affidavit indicating such. 4Conttactors tbat check this box mmt attached an adaonaI sheet showing the name ofthe sub -contractors and their workers` comp. poficy information. lain an employer that is providing workers' compensation insurance for my employees Below, is the policy and job site lnformadon. Tnsurdnce, Company Name:, Policy # or Self -ins. Lic. T Job Site Address: �7" �i�L ��/� ,� ' citylS`�e/Zip: Attach a copy of the workers' compensation policy declaration page (shote the policy unmber 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 $1500.00 and/or one-year imprisonment, as well as civfl penalties in the fora 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 lavcsFiga€ions of tb-- DIA for s' suranez cave -rage. verification. I do Hereby certify unde a pains andpenalties .pedirry thgzt the information provided above is true and correct. i Qf w—j use only. Lro not write in this area, ta -be'nomphaed by city or town o,{icial City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Eleetriad Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone r' 3 {. i Iii1 ;{ •' ad Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. pursuant to this statin, an employee is defined as "--every pe rTson-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 t1w legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal eatity, employing employees. However the owner of a dwelling house having not more than tiuee apartments and who resides therein, or.the occupant of the dwelling house of another who employs persons to do maiOtemance, consirucdon or repair work on such dwelling house or on the grounds orWding appurtenanttihereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§BC(fs) also states that "every state or local fiicensing agency shalt withhold the issuance or renewal of a ticenseor permit to operate a business or to construct buildings is the commonwealth for any applicant who has not produced acceptable evidence of coimpliance 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 mxtil acceptable evidence of comphm= 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 -co b=tor(s) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. I mited Liability Companies (LLC) or Limited Liability Partnerships (LLP) wish no employees- other than the members or partners, are not required to cavy workers' compensation iumnance. 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 Z applic21i(M fust the pit Or% license :s being reAuesL-4 not It D -_===t of Industrial Accidents. -Should you have any questions regardiag the law or if you are required to .obtain a workers comVensaticmpolic y please call rife Department at the member iisieedbelow Self-insured companies should enter 1heir 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 fvr you to $11 out in the event She Ofnce of Investigations has to contact you regarding the applicant Please be sure t> fill in. the p= itllic�me number which will be -used as a reference number. In additiov an applicant that must submit multiple permidlieense 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 beenn officially stamped or marked by the city or town may be provided to the applicant as proof _bat a valid affidavit is on file for future pem mits 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 (ie. a dog license or pemnit to bum leaves etc.) said person is NOT required to complete this affiddvit - The Office of Investigations would i%e to _hank you in advance for your cooperation and should you have., any questions, please do not hesitate to give IIs a tail. The Department's address, telephone and fax number. The Cammonwwlth afMassa&usetts I3gm nment of`Fndushial Accacmts Of of hNeskas4me- 6W wLtdngton Ste: eel Boston, MA 02.111 TeL * 617-727-49-DO-ext406 or 1-877 MASSAFE Fax # 6,17-727-7749 Revised 5-26-05 vt .mass_govfdia OP ID: COHA ACO/2O" `...� CERTIFICATE OF LIABILITY INSURANCE DATE (M1WDDNYYY) 10/28/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificabe holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemengs). PRODUCERCONTACT Phone: 978-688-6921 Macdonald & Pangione InsurancePHONE P.O. Box 428 Fax: 978-688-5350 104 Main Street North Andover, MA 01845 Craig S Childs ,,,AME; Hannah Courtemanche AAI CISR FAX Arc No E ; 978-688-6921 Arc N,3:978-688-5350 E-MAIL ; hannah@mpins.net PRODUCER CUSTOMER ID#:ANDOV-7 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Andover Plumbing & Heating Co PO Box 262 Andover, MA INSURERA:UtICa Mutual Insurance Co INSURER B: Safety Insurance Company 39454 INSURER C : INSURER D: INSURER E : INSURER F . COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE RDDL SUBR POLICY NUMBER POLICY EFF MMIDD1YYYY) POLICY EXP (MMIDONYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 4481325 10/26/14 10126115 DAMAGE TO RENTEU_ PREMISES Ea occurrence $ 50,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE S 2,000,00 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 X POLICY iECTPRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANY AUTO BODILY INJURY (Per person) $ B X X ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS 6230887 10/26/14 10/26/15 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ (Per accident) X NON -OWNED AUTOS Collision $ 50 Comprehensive $ 50 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,00 AGGREGATE $ 2,000,00 A EXCESS LIAR CLAIMS -MADE CULP 448141 10/26114 10/26/15 DEDUCTIBLE $ $ RETENTION S WORKERS COMPENSATIONWC STATU- X OTH- A AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECIITIVE Y I N OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A 4481326 10/26/14 10/26/15 T Y LIMIT ER E.L. EACH ACCIDENT S 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500100 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, ff more space is required) Plumbing and Heating contractor. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Plumbing & Gas Inspector Building Dept 1600 Osgood St Bldg 20 #2-36 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 4%GOMMONWEALTH OF MASSAMSETTS, Date.. Z/� X `........ TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �SACMUSE This certifies that .. S1lA�%!? ../�.�/,S/`T�'r....... . . e has permission for gas installat'on .. G ! �? .. �,�*„Apui),- in the buildings of .... .......................... , / v� ,eve °....... . at ,%��...... � ... ........ North AndAver,,Mass. Fee. `�Oi� . Lic. No. ?4 ,� /g ,hfnr GAS INSPECTOR Check # va /1 s • � E t ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ /Y �w,d mV -r (" MA DATE b PERMIT # JOBSITE ADDRESS ,� !/G. OWNER'S NAME _S�G�ho,u ,4,V/�es1 GOWNER ADDRESS s TE G9 - S�3yoAx TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL CLEARLY NEW: C3 RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES EI NOD APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I Jr [ I- I L= BOOSTER_ - CONVERSION BURNER COOK STOVE _ I . _.._ m _`i. i- —T1 _ ___ DIRECT VENT HEATER DRYER2 FIREPLACE FRYOLATOR FURNACE J L. =--_ - I_-�- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ( I -_ �j j ( _-I �- I MAKEUP AIR UNIT OVEN POOL HEATER _ I -- I I I ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER J _! ,-____._._.i OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES -_1 NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ll BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER �1 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 /13 PLUM BER-GASFITTER NAME _.rl.f �� �! LICENSE # SIGNATURE - _ MP MGF JP 1f JGF r- LPGI Q CORPORATION Q# PARTNERSHIP El#= LLC [3# COMPANY NAME:./, ADDRESS CITY �i�(,/� �� I STATE �ZIP a TEL FAX CELL EMAIL - t\ H °z 0 F U W a A W r z0 a O S, El W '= w � a W 55 w � a o a a a �C U F� J H 0 - CL a x w H O O H U W a °a The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations Uf 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip:, Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. FJ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *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 a're 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 Policy # or Self -ins. Lic. #: 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 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 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 c ertify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractorTs) 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Coxxonwoalth of Massachusetts Department of Industrial .Accidents Office of Investigatiions 600 Washington Street Boston, MA, 02111 TeX, # 617-727-4900 lat 406 or 1-877:MASS.A.FF, Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia �Ir11� f Date . � � !i K a Q NORTH TOWN OF NORTH ANDOVER 2t1lED �6 q41 FOA IT FOR GAS INSTALLATION • � � � `ems �9SSACHUSEt This certifies that . has permission for gas. installalion �%. ' fi i l+.�' ... �..`.! :. ' ? ........ in the buildings of �� .. ,,� f . .. .� ."c': .............. . at . f : fry .(.� .{ . ..?�........ , North Andover, Mass. Fee.#?.!" Lic. No:4.�.1 ... .......................... -GAS INSPECTOR WHITE: ApplicantL CANARY: Building Dept. PINK: Treasurer GOLD: File 1kbbAk;HUSETTS UNIFORM APPLICATION FOR PERMIT TO DO OASFITTINQ (Print or Type) 2 ? NORTH ANDOVER , Maas, Date 3 S;& Building Permit -#--t-- Location /4 w d t h L, t NO I h d a V er h Owner's Name J—Qc:lL G V 0 New ❑ Renovation ❑ Aeplacement Plans Submitted:. Yea ❑ No [p rn i . i • Aue—esMT. .1111AAEMENT IST FLOOR !NO_ FLOOR SRO FLOOR 4TH FLOOR ATH FLOOR ATH FLOOR 7TH FLOOR ATH FLOOR rn w �• 0 ~ Z d -+ M w h V d F y s h X O pap 1d' < 14 = s O h ac < 0 M M- rrl 0, 0 H YIat X efit O .M <tX 447 F Z J� X h rr sM� O o.�a11 .1 r O d ti �, o 0 a0t sy o s Check one: Certificate Installing Company Name POC/L f-/ Corp 0 Corp. Address_ _ 8 0 � 7 2 . �' [i Partnership ❑Firm/Co. Business Telephone_ Name of Licensed Plumber or Gas Fitter 20 b el, � RI o u C h e i l .0 INSURANCE COVERAGE: Check one I have a current liability Insurance policy or its substantial equivalent. YeaXr No If you have checked yes, please Indicate the type coverage by checking the app roprlate box. A liability Insurance policy Other type of kxtemnity ❑ Bond O 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: nature of Owner or Owner's Agent Owner ❑ Agent ❑ ( hereby certify that an of the details and information 1 have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work end Installations performed under the pe rmH Issued for Ihla application will be In compliance with all pertinent provisions of the Massachusetts State Gas rN d Ch of an War 1R2 Ute General LAWS. TI License: v> ffP O u';Mber Signature of License Aumor or Zias eFiII Master license Number Q Joumeyman-------, 11r' novED (OFFICE USE ONLY) N° 43'10 Dater c1 �. rr1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING � �SSACMUSE` /�1 This certifies that-y"�""`''�...... `.. ................ has permission to perform_. -%. ...<.�<< . ;fi-.� ......... . plumbing in the buildings of . C-�r� T ............... . at ..!... Z� �e-..v .........`.. / Orth Andover, Mass. Fee. 1.3. `'.. Lic. NO. �.-, ........... GPLUIINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer NORTH ANDOVER, Maas. Data 6c B 3 _I0 Building It Location _._l4 (k)a1 yAu L IAUe.. Owner's Name 3ze.uer Antliony z -5 -- New ❑ Renovation O Replacement ® Plans Submitted: Yes ❑ No ❑ FIXTURE6 Check one: CertiPcate Installing Company Name ANDOVER PLBG. & : HTG. CO. INC. ®Corp. 2122 Address 20 AEGEAN DRIVE UNITI 10 13 Partnership METHUEN MA. 01844 ❑Firm/Co. Business Telephone 978=685-8383 Name of Licensed Plumber runggi BARO. INSURANCE COVERAGE:ec ons I have a current liability insurance policy or Its substantial equivalent. Yes Q No ❑ It you have checked yg, please Indicate the type coverage. by checking the appropriate box A liability insurance pollcy (9 Other type cif Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the 11cenies does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permR application waives this requirement. Check one: Slonstute o et or Owns a Agent Owner ❑ Agent ❑ I hereby malty that alt of the delafts and information I have eubmiHed sot entreat) In above appfica are true and accwate to the best of my knowled�e and that as plumbing work and InstaAatlons performril ed under the alaved fol appilcation Will be h compliance with an WInen provisions of the Mauachusetts State TH)e Ctly/Town AFTF'nOVED (OrFICE USE ONLY) Ueensa Number 9983 ' Type of MumlAng Ucense: Master [s1� Journeyman 0 st » w w Is be Hr°i s w is J t w < u �' M a 0X °L = FU W • 2 :a M- u M s S at O w w r< w w w �. �x� < w y w as 0 • �= °<` 0 s t a 1- rJ y p. O s at M 1 s a. 1L K r J M O p tO = 0$ M w_ 0 V J• au•—eeMT. •A69NKHT 16T FLOOR !HO FLOOR $RD FLOOR-. 4TH FLOOR /TH FLOOR aTH FLOOR. TTH FLOOR j aTH FLOOR Check one: CertiPcate Installing Company Name ANDOVER PLBG. & : HTG. CO. INC. ®Corp. 2122 Address 20 AEGEAN DRIVE UNITI 10 13 Partnership METHUEN MA. 01844 ❑Firm/Co. Business Telephone 978=685-8383 Name of Licensed Plumber runggi BARO. INSURANCE COVERAGE:ec ons I have a current liability insurance policy or Its substantial equivalent. Yes Q No ❑ It you have checked yg, please Indicate the type coverage. by checking the appropriate box A liability insurance pollcy (9 Other type cif Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the 11cenies does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permR application waives this requirement. Check one: Slonstute o et or Owns a Agent Owner ❑ Agent ❑ I hereby malty that alt of the delafts and information I have eubmiHed sot entreat) In above appfica are true and accwate to the best of my knowled�e and that as plumbing work and InstaAatlons performril ed under the alaved fol appilcation Will be h compliance with an WInen provisions of the Mauachusetts State TH)e Ctly/Town AFTF'nOVED (OrFICE USE ONLY) Ueensa Number 9983 ' Type of MumlAng Ucense: Master [s1� Journeyman 0 5 3 �� u Dater ,�2 .(........ NpR71y TOWN OF NORTH ANDOVER py,e,h•OC PERMIT FOR GAS INSTALLATION This certifies that .. (A -:-t ........ ...: /.I........... . has permission for gas installation ,....- Y -. ....... in the buildings of .�� !': ... .......................... . at.. ................ North Andover, Mass. Feer? ...... Lic. No. � �� ... i .�� .-z: ,.:.......... . 'GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date 23 OT j building 'Location I q Wal(tt lave_- Permit Owners Name 5.Leveyn lan ht,n New '7 Renovation 17 Replacement Plans Submitted =j • s' FIXTUR_c (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLBG. & HTG. CO. INC.Q Corp. 9l?p Address 20 AEGEAN DR. UNIT 1 10 Partner. METHUEN, MA. 01844 Firm/Co. Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter GFORCF I ARoSF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity D Bond Ej 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 coverages. Signature of owner/agent of property Owner 17 Agent M 1 hcreby ccrtify 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 performed under* Permit iuued fox this application will -be in oo luace with In Pez"=t provisions of tho Massachusetts State Cas Code and Cbaptes 142 of the General Laws. By PE LICENSE:. Plumber Title asfitter' Sig ature of Licensed City/Town: Master Plumber or Gasfitter Journeyman 9983 APPROVED (OFFICE USE ONLY) License Number N y V z Q arj • y N OG N 0'i tt: .) fA = • o! 'mss 0 V B3 S N x o Oo H U N d = a O c a z l N Q N t3 w C7 us w _ .. V) W ... r I- 4 ... trs cc 0. O G w y •t U&LU w x_ a w W wcc O us t- 1- x H W O }�. z o? w t- m a t= :. o c� u. a t7 .a tr y a a 1• o SUa—$SKIT. SASEMEHT j 1ST FLOOR 2N0 FLOOR I 380 FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLBG. & HTG. CO. INC.Q Corp. 9l?p Address 20 AEGEAN DR. UNIT 1 10 Partner. METHUEN, MA. 01844 Firm/Co. Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter GFORCF I ARoSF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity D Bond Ej 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 coverages. Signature of owner/agent of property Owner 17 Agent M 1 hcreby ccrtify 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 performed under* Permit iuued fox this application will -be in oo luace with In Pez"=t provisions of tho Massachusetts State Cas Code and Cbaptes 142 of the General Laws. By PE LICENSE:. Plumber Title asfitter' Sig ature of Licensed City/Town: Master Plumber or Gasfitter Journeyman 9983 APPROVED (OFFICE USE ONLY) License Number Location No. 9-3 Date 40RTh TOWN OF NORTH ANDOVER Oi ,••o I•1�00 i 14 • L S Certificate of Occupancy $ 9 cMuBuilding/Frame /Frame Permit Fee $ s�st Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 0—b �•-- Check #yp, © 6 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OOR� A ONE OR TWO FAMILY DWELLING a� jDEMOLISH SOW"( BLUDING PERMIT NUMBER: /' DATE ISSUED: SIGNATURE: 'Aw Building Commissionerffaspxtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Prop A a til l� 1.2 Assessors Map and 3 3 Map Number Parcel Number: Parcel Number 1.3 Zoning Infomration: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RC4qWred Provide ReqWmd Provided Recmimd Provided 1.7 water Supply M.G.L.C.40. 34) 1.5. Flood Zone Infmmdios: Public ❑ Private ❑ zow Oviside Flood Zane ❑ 1.8 Sewerage Dirpoul system: Municipal ❑ On Site Disposal system ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT istr!Ct: Y,33 No 2.1 Owner of Record 4vt��o yq�C Name (Print) Address for Service l Signature Telephone 2.2 Owner of Record: Name Print Address for Service: t SiRnature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Su icor: Licensed Construction Supervisor: / PLicense Add (/ CJ q �(J�. Si a Telephone Not Applicable ❑ Number L G Expiration Date 3.2 Reegi/tered Ho Im rovem t Con ctor C /A Not Applicable ❑ ` y o---�( 2— Company N e Registration Num GGG 3 Expiration ---Dais Address j Sienatu a Telephone V 0 z M M z a SECTION 4 - WORKERS COMPENSATION (KG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check a ble F, Failure to provide this affidavit will result New Construction ❑ Date Existing Buildin" . Repair(s) 0 Alterations(s) 0 Addition 0 (a) Building Permit Fee Multiplier SPAN 2 Electrical (b) Estimated Total Cost of Construction Accessory Bldg. ❑ Plumbing Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I RRCTTON 6 - ESTTMATF.D CONCTRTTVTTnN rncTc I Item Date Estimated Cost (Dollar) to be Completed by permit applicant OincIAL USX ONLY 1. Building y� (a) Building Permit Fee Multiplier SPAN 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing HEIGHT OF FOUNDATION Building Permit fee (a) x (b) --'- 4 Mechanical (HVAC) MATERIAL OF CHMNEY 5 Fire Protection 1S BUILDING ON SOLID OR FILLED LAND 6 Total 1+2+3+4+5 Check Number vao a.aava. ,� V•, 1.La`AV alaVat� aaVi. aV DL' l,vD1rLL'Izip WrMrJ 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. i Signature of Owner Date SECTION 7b OWNER/AUTHORIZE AGENT nF.Ci.ARATTnx 1, " VA 4 .11J.AVL-K,as Owner/Authorized Agent of subject property Hereby declare that the statements � information on the foregoing application are true and accurate, to the best of my knowledge and belief I , An 71-- A 1111L 11—Y. u Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND 3 SPAN DIMENSIONS OF SELLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X ------- MATERIAL OF CHMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE rq S` t��f`rr .*a`dtrxrs pfft5�?*sP� tf`Rt a T i ig M� �A 1h T rt..K` I.t; ;�ti t M+4,� ;wit .�k:�,�cc 1t" + 'a �� -PROPOSAL' t+ II I I I'I'IIr. a� tvx .. � t f I I I I I f III � . >, t 7 t� g „t 4 ALL `i P S :OF t O S S °i S rk j t �e x� si•�4 TP i r; III II:I.II &fIR OFt �►EV� S n r I ( F �' {� lei Xv +„S S< _ ..:4 Rt,.At �irrr;'SCt '�}%.'4�`r;y�''f..#rt�rty'J J , •„i {. 4+t4 L 1 p� q F) ” M h A F.E Ti OFI✓ICS �71�3) 251 71$1, Ef> { { e i19�d � �. } , • i� • +..� xt �� 't, t n �f�i` ,tw` iy' `` < srf�r7'S•�,s� r"'4 'FAX "(97f) •, t� 'OUALITY 't r, www.woosterlroii� hl .cdr�l x$u q Put Your Roof under Ow profe0lon of Our Umbrella s+ + ' , /' � ,� C•9 I ��A 4i r E -Mail: ILOVER OFS@a�li ��►m ' P.O. Box 8051, Lowell, MA 01853* , s J + Es`�4�• Proposal Submitted To s,Wprk 1`bJ±i`I�eiforrridd,At ` Name Steve An hong Sfrt _: • '.S 1 -. I, _,� -, +r yr, tt t� �a71y c t.., �.� ,est srJ�if,• ) #�, Y, l.. °_t'1. a C p . Street 1.4 .. Wa1n..? 4:: Ave.. 358i i � t S i' k•� M, - -_r.}� 4n y� Is Y A. 1v ��?L.'"✓w�t's•�?�fi �r _t City No. Andover State t ' ".�Gode4 �� 1f State NSP, Zip Code 01845 ax Number ¢ f 4i� 1 M t it h� Telephone Number 853-3908 hone Nu " ar E x' vt�'_ :,, r t` •' :�� �„ , s {,� t�:� y� � t y'sa .;�3 �v�#' �rK r�: k�. h^ wtons", '.,t$ xEt'�°,?i�+� We hereby propose to furnish the materials ;arid peri?6 ` ii `t neGe'Ss YGr`. hO'✓e� pW�ti rti}o the �(13wiii+ " :Y•<` d a.. a - '1 t ra ,,f,�b i : '�,�y� y'�y,, a� aa` /,,',t.,{ , y� 'rt '•,f c, tr-Yi ..t ry. h�, r,T a., ; ,.r. .:t y.+,�. ..t, '• ,.. ts�x 'l •?mIJ,Y� y {j V 4(iVQ:1f eYJ ,g 7 .� • .yx.� 1f i' ,:A -' .isf ,, I,I 'l ' ac l in'4 'iZE?a `+n r , r ot:e t EGA 'cTi tz i .• @1" t'} ♦ a inum _diipedO nate �I� .sI''3� .'tl3 o3l.i bieyt`St pIv i1= i {. µ rt.:i a d 'Wat:eY r br3t on gal eaVES•4 ,3 r E.: i tt t x Iiij. r,' N. I c1iJC' tttaa nc e'.. oo' wl Zh 15 room i e�.4v � tE i ;(•, A� �� �tr frw �N QTY i1�. e �-'a ;rTe _ Y 30' ear" 'shy n` 1e hand n'a�e,.+'° `t, � d r r n. i n ritr t E , and1v�AtEIr;+,r r�: d€e '� i 4 q ,� :1 r..p, t .. r z? z x aW:r t, e Mtt xxi x z ;Sia 6� 9 . LZE�ti:�` cU81C� ,:zJl1S USE; ©._" c 11 CaJ. 38 tr y_`"8, .:}.'_ ..f n•f 7"0 ...., -OPT10N' _T&J1A 4,d Scoff y&Yiat rid e' ve it 't 'b'�3;d�1b, 41'S-1 504 0O'l. �t ' ri + •, - .. .: ., v - �• i4"+.: `"�i� x >^ x 4,9r,'.1a �'h1 L°9'� %+4� Workmanship` guaranteed for years: We arse fully irtsure''ith workers'cord ��� Y. � _ t:.r A,.. � x' •�,; ...,, {: 1 f, '<E ^... �''� `73"��#�f �._ s�f��'� � f `:. `s -N'`. ._ ? � eEk'4;r�. '�'��{.r�ai Please return.copy of proposal t A. r" C, + a � Wit•-.�ttV 'fir � a v .• x �t y t.��.�,`s,. t�`� a �5�,.`n � � �.rer� ,. All materiel" is guaranteed to` tie, as' specified, and the above work to be peormed to accor1 With 18 s`�pCica�;� ;. tions submitted far Above work ahi� tCc> npleted:in�l-'�uh MntiaP orkman, artier � µpa ' °"'. ($ 9 , 8 5 0 A 0 ,with `payfients to be made `as folio rS�:.Job°`pKd up e --i spoo-ully si ' 64'11` Dor bureierences '" r++ t`'NO 774 is;�ptro r Fully Insured f .. 9 q.4- '� r+.� js t:L:y fA'is �',: � ai '*+�[ F .: . ro -..'y-r^R.*.'•' ` `", F}..•—'.�.'r."r•4+w'�bvtittrvxi,llsx i{ire:4. •���),�% •:� .1�:�..»1.,z'� .a,��� Y n °h,. o The,ab va•e i} ti s an ion ona are sa sfecii e e tl rn,ttj1 �" x >tr c 1 s r ;r x ° " t1/1�'��i �ileit will' rdBS Ocflf i$tfbiV$l§ z b> 4 ` ` r� 'its r'F�'1 �•' � rr�; r:'3� y�,{tet. •x� } ,.: �;-t y:�;� • i ` �' e � 9,� �c�� 9�` -�' r ! 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P.O: Boit 850984 ,s gZaini;ree MA 02185 �,, • rl;.?^�.� .,,<-�. ;r a �•.� •� a Ph6nAt `781t-048.8600 �Ixs7 84 W8507 i ,� NSUit i?SAFFO_RRlA1dU lY RAGB NAlC ' .a.,:u.,iitrLi,+x�} { aa� �P•3 oil pti �r lR1Pti�� Mie >iii�• rJ r}{3i Ftt IN9.11?itl1� 4 s a 9J.iFr�llr,.s(tf .e .2• �rCn# K�Ct , r sf� •f.e 1y ��1Oki t#.. yild^^7FAA � �r INBUR>:Rb.. f�t7w�3.• i�sN' Jt`7 G 4ad a iir, 7diC�t,d Si } 3.k,. p' ► .l y i �Uk '=—✓ .S(rµ,i`4r�t � �. �5i.- i. ='31.1,,• d,� {_ -.QO � t�`� r . tt-. 5)�3'vil.{'r4 .a nit. i.9git +ta 4 COVERAGES 7HE POLICIES OF INSURANCE LISTED BELOW HAVH SEEN 15SUED TO THE INSURED NAM60 AWV6 FOR THE POLICY PERDU INDICATED. ge ss Fit) OR NO e PJv REQUIREMENT. TERM OR CONDI7K5N OF ANY CONTfsACT dR OTMflR DOCUMENT WIN RESPECT Y0 WHICH THIS CERTIFICATE MAY 9E ISSUED OR P•VAv r""'AIN, T" ""URAN" AFRO"'- t3Y TH6 PQL""' D_@5GR" ) H6A9IN i8 $iJi ACt TO ALL TME TCRMS EXC�U$ION6 ANb t`ANOITIONS OF SUCH 1 . AUGECtATE LIh11T$ �ili>WN MAY) ��E11111(" pY•hAli�6jAiM$'�,ii ' ` p �``` , <-• x �•: i k' r L. v pOLIC G.� y T x, L K !; "� LT. _ t�7i�Ca ktZAN�di9 4?.'Pb�fQYtU6ts ,.,-� t z1`,�t�'x1N W1� f< e s �, r # ti 4.r; r�+i}ILj` Y41,N9QJ'IV�!'s F �.9 fit. E ••b} tiEN ER LiA91Li1 Y i 3 i ,! Se'I ' Sd c► q . t i3 !'i ;rt Raw+ V" f'AFA6F3CIA[ bENEfYAL 0ABil.lVv 1:4 r r 1Y p h ■�� F� /§,g,�,;•, yIpp3�ix1 a { �pwKt, rE4 CLAIiA'6liIKYiw II X Worksite Pall 1d I PRobuote comoi6oAbb 112 006`, 0 GEt-rLAGGtRGGATELIM APFLIE6PER;I POLICY r---' rRQi ~� LOC JECf _ a ; rr(will �b �INOLPt Lpdi1 $1 i 000 1140 j AUTOMOBILE L1A91LITY r (EE'dCt� +I� p.wvauTo . 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Supplement Cal~d 4 at. r i r� rrQ v,r.K s P Expiration 6/23/7006' i4 /23/2008' CHARLES J. WOOSTER ROOFING` STEPHEN WOOSTER P.O. BOX 8051 LOW ELL MA 01853 b Update Address and return card., Mark raven for ehlut<gtl;*, [� Address Renewal . D Employment': OPS'C!`1 0 "M-04/04-G101216 11 rr�1 .{'ryj k +.Y 5 /fin i r �..! to P rt i�AV Board of Buiidin a ul#tons � - g g _-�1- One Ashburton Place Rm 1301a 1� Lirenee: CONSTRUCTION SUPERVISOR LICENSE, " irthdat�$� ;;0 A t'' t �Y$'t��,,.' t, Number, CS OIJ42G0 Lxpiree:05111/2005 6 , i ' .y S.,dI �,1N �• # l.Ej ,� '{ I `7� � 1ct�^,�2.. 9� �� EIS t'f 1fJ{ti+ j ( t f t.'IIAR1A-'s J V 0(-),1°I`1;l3 i1� i ' Al '�� 1 { tqr "� � s 00 I1C)X 8051 �� �' ► £ 1t t , f �q yyqq y i 1�' {�i Jii . � t !4 {l i,. b , an y d! t {' 1 ¢A•; f k�� t [ F`+° i � 11'}}�J 'tt i , i A •�•,.: � n-i. N t AAy �a'�qY 4 11Y.�' fi nt3 LP • ll ��� ,, ¢ { la tqr �q h €a (+( : a .. r ep tap toi''r0�telptand ahotipo' >dbbllOn;� ' t � F..b i, ry55(,I•a dt } tai k t Ip- }boa Wou i irwg#egulAa oo x . One Ashburton Place'Ro{�tt,�, 1.JotJtdlla, Mas8achusd�ts"n ><,,l i ..,(• ,.1 a< ,4 1 Z •°-S.x - fi Home Improvement' iI`d�rto%t ��'�'�U � ,�, q• rtutfa'+W �4ri 1 '',t.,t ¢4T' _y�!t. "1v ,.. d`�'J;iP {; �•' IStratl � �¢ Ut CHARLES J, WOOSTER ROOrN � a `( ,�1 / ;£ .t rLr; ; I`" . ft,° �► ti'x,; � a -r Charles Wooster P.O. BOX 8051 ME+A Oi Ev3 ` o,. P � ',• t ,<< . it . �. � II-f(rtr��f - °��` ¢•. r,I 1 " '' �r. r + f: �t+, »iris �`}• £ +�, ;' ,.+; , trY ,d hY `N1}�•f! t tri}RiQ j!yF - {i 1 ti,,¢�r1.`yfi - ��iyri`I L.`"��.�J'ri`�S��gb.,'', �{friti4�•i�'�i �-..bF.{ �_ r � :'ki'� Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Worlkers' Compensation Insurance Affidavit Please Print Name: Location: Clty Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing my employees working on this job. Od Comoanv name: Address City: Phone # Insurance Co. Policv # 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 $1,5W.00 and/or one years' imprisonment_as wetLas.civil.,penaltiesin-theformnf a -STOP WORK_ORDER..and..afine of.(.SIo0..00)�jtay 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 Jndqy�he��ns and Print Official use only provided above is true and correct. do not write in this area to be completed by city or town official' City or Town Permit/Licensin ❑ Building Dept []Check if immediate response is required I] Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other 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 c 11, S 150 A. The debris will be disposed of in: (k Location of Fa 11 , Sj`gr�ature of P rmit Applicant NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I&0 E a t y W o 0 CcO N cc O O.� p,C O ea m C :Z O V Ea •O. C 0 d :4: E� S iaQ&.R0 C w 1:ts cm cj O 2.- ti o c ;a Of 0.3 y C C � 'O m O = C y C4 W CC C* W ,:Q t m :�0 ""rte c IxC 0 Q .O O m MA O oCO3o S O. C a go m C Q = m :m 3 N 0 ym� om c +r s -E ice= ,O a Go o COD CL ��4 CM Os 32 -M M's F- z s CL=,- cD zip I C cm C 'w C.— D Q h O O '� m m co CLQ_ �3 � �0 Lm a CL CMQ o c cc C3 o C Z CD 0 CL C.3 h O C cCL — '- c h 0 W 0 U) W N o� LLI W C9 W U) a a a w a cn w � ca U w w w w a x° chi w a a�' w rA vi o A o 0 CcO N cc O O.� p,C O ea m C :Z O V Ea •O. C 0 d :4: E� S iaQ&.R0 C w 1:ts cm cj O 2.- ti o c ;a Of 0.3 y C C � 'O m O = C y C4 W CC C* W ,:Q t m :�0 ""rte c IxC 0 Q .O O m MA O oCO3o S O. C a go m C Q = m :m 3 N 0 ym� om c +r s -E ice= ,O a Go o COD CL ��4 CM Os 32 -M M's F- z s CL=,- cD zip I C cm C 'w C.— D Q h O O '� m m co CLQ_ �3 � �0 Lm a CL CMQ o c cc C3 o C Z CD 0 CL C.3 h O C cCL — '- c h 0 W 0 U) W N o� LLI W C9 W U)