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Miscellaneous - 147 HIGH STREET 4/30/2018
147 HIGH STREET 2101067.0-0039-0000.0 �.- •-�••-....rn.---_....may,..+"•+.�'�-.-.-.ti.w '-..4�...x +�-n.'_`-r-.,...._ _ ., _._ _......._ _. _ 1 Date.... ll.r ...... 9 of T TOWN OF NORTH ANDOVER ° n PERMIT FOR PLUMBING ,sS�CHu This certifies that (Jt has permission to perform......... . } �k.,....w..�� M ���".. .. "t plumbing in the blildings of............. .? 5�- ... ..,................................. at.:.....:......... -' , North Andover, Mass. Fee0............Lic. No.I�. .o ...... ................................................................................. PLUMBING INSPECTOR Check# 4 a4a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I CITY MA DATE -..-. -PERMIT# JOBSITE ADDRESS OWNER'SNAME OWNER ADDRESS P FAX TEI151�:&4-0— L TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL E] RESIDENTIAL PRINT CLEARLY NEW. Z RENOVATION;. REPLACEMENT: PLANS SUBMITTED: YES I NO[] FIXTURES I 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 GASfOJUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _r—J,r- ............ .......... ........... .............. DEDICATED WATER RECYCLE SYSTEM DISHWASHER .......... I . ................I ....... J ................ DRINKING FOUNTAIN ........... .......... FOOD DISPOSER _..............,,.1 FLOOR/AREA DRAIN j fill INTERCEPTOR(INTERIOR) ......... KITCHEN SINK .__._...___I LAVATORY ROOF DRAIN ... .........._..I. ...... ........ SHOWER STALL SERVICE I MOP SINK .......... TOILET URINAL WASHING MACHINE CONNECTION EUJ ............. F WATER HEATER ALL TYPES . .__.....I .............. E- i I WATER PIPING i .............. OTHER 7===== r-7 F— INSURANCE COVERAGE: I have a current Lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 1 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BELO',1V LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY [j BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT 0 SIGNATURE OF OWNER OR AGENT A I hereby certify that all of the detalls and information I have submitted or entered regarding this application are true and agWrat o the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compjjpReg' a] eminent provision of the Massachusetts State Plumbing Coda and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# FT6 SIGNATURE MP ip D CORPORATION[j- #=PARTNERS 0J#=L0#'t2$y—k—Z1 COMPANY NAME - ADDRESS 7' all CITY1,_&V STATE ZIP TEL FAX CELL .11 EMAIL -AkNI-1 F V d _ 3 3 b i Date....... 2 NORTH ID p3? °°p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION gCHUs� This certifies that `.--.........-��.................i............. ' '.. ............................................. has permission for gas installation ..b.?�. ............... in the buildings of ....... ^ " ' ams North Andover, Mass. Fee.. ........ Lic. No. .......................... ..................................................................... yy � GAS INSPECTOR Check# i 6426 �U 1 f: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY __ f��!�.Y`�"1 v'� . MA DATE! "L _7 PERMIT# I H ib JOBSI7E ADDRESS OWNER'S NAME I_- ✓ - p G , -. OWNER ADDRESS � 7 �..��� ,~.��-_,::_�---_ �TE AX TYPE _II I`YPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL „--) RESIDENTIAL PRINT [ CLEARLY NEW;L-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES®J NOD APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ” BOOSTER J 1 ._J CONVERSION BURNER I - -1 -- COOK STOVE - _ ) , _I ,I 1 . I(^� _^J _ _1 . DIRECT VENT HEATER DRYER FIREPLACE -- FRYOLATOR - FURNACE GENERATOR r..-1( ._.JC.� 1 ,- _-1 - I( I C __-i l _ I .. J .__ 1 I .:.. _I GRILLE INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT OVEN _-.-) POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST ....,. J UNIT HEATER I UNVENTED ROOM HEATER WATER HEATER [-7777-1 f J=1- - i -J -_-1 1 ! r .. - � �r�i 1 �J[-_►r��1 �� :J r -1 _1 G_I - - _ _�r .T-I ,• INSURANCE COVERAGE have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES __ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [--A BOND IJ 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 DJ AGENT [m�f SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliant 'h all ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEc?►1_�.._ 5.. :._.-.,.. LICENSE# SIGNATURE MP I) MGF[ � JP 0 JGF[j LPGI E] CORPORATION # PARTNERSHIP F.]#=LLOWL M.- COMPANY NAME: �`Atit'� �r � ADDRESS -13. - CITY , ' - - -._.. _J STATE ZIP TEL FAX FAX CELLt�> �- EMAILL, w1\11 .� . . ,- � a � { ,- t ., 1 .' �,. ,t -� V The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Lesibly Name (Business/Organization/Individual): A-_T:"-,0 � Q c Address: f3 j/Wts •t {fid City/State/Zii;7 Phone#: ,3'�CtY D©'3 — i Are you an employer?Check the appropriate box: Type of project(required): l.F-K. a employer with employees(full and/or part-time).* 7. 0 New onstruction 2.0 I am a sole proprietor or partnership and have no employees working for me in $, emodeling any capacity.[No workers'comp,insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. 0 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance) 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am art employer tliat is providing ivorlrers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: q63 ZO Expiration Date: 57A &1h Job Site Address: a1 � 100*W ODRf City/State/Zip: - Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.MGL c. 152,§25A is a criminal violation punishable Ivy a flue tip 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and top ns and p alties of petjuyy that the information provided above is true and correct. Signature: —Date: Phone#: Official a 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ® DATE(MMIDDIYYYY) a� CERTIFICATE OF LIABILITY INSURANCE 06/2712014 THIS CERTIFICATE 15 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 endorsement(s). ACT PRODUCER -NAME: JEFF YOUNG THE ANGUS GROUP INSURANCE AGENCY PHONE •603..,421-0021 ac No,:603-421-0052 116 ROCKINGHAM ROAD a 0 1ILL :ANGUS ANGUSINSURANCE.COM LONDONDERRY,NH 03053 PRODUCER U OME IDM: INSURERS AFFORDING COVERAGE MAIC M INSURED INSURER A:MAINE MUTUAL(MMG) INSURERS:UTICA NATIONAL INSURANCE GROUP EXTRA TIME ENTERPRISES, LLC. INSURER C: I 13 JACKMAN RIDGE ROAD INSURER D: i i WINDHAM, NH 03087 INSURER E: I 1 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. -OFINSRI TYPE ISU POUCYNUMBER 121 YEFF IPOUC EXP I LIMITS LTR l A LGENE�RALLIABIUTY SC10939324 05127/201505/2712016 EACH OCCURRENCE s 1,000,000 MERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S 250,000 CLAIMS-MADE Ir OCCUR MED EXP(Any one person) s 5,000 PERSONAL&ADV INJURY 5 1 DO0 000 I I GENERAL AGGREGATE s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP A( 5 2,000,000 POLICY I PRO- I I LOC Is A I AUTOMOBILELUIBIUTY KA10939324 05/27/2015 05/27/2016 COMBINED SINGLE LIMIT 5 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) S ALL OWNED AUTOS BODILY INJURY(Per accident)I S X SCHEDULEDAUTOS PROPERTYDAMAGE S TIRED AUTOS (Per accident) NON-OWNED AUTOS s 5 A X UMBRELLA LIAO X OCCUR KU 10939324 05/27/2015 05/27120161 EACHOCCURRENCE' I s 1.000.000 CESSUAe AGGREGATE s 1,000,000 CLAIMS MADE DEDUCTIBLE S RETENTION S Is COMPENSATION WC STATU• OTH- WORKERSCO 5/10/2016 X B : 4637069 05!10!2015 0 _ AND EMPLOYERS'UASILITY Y 1 N ANY PROPRIETORPARTNE.^JEXECWTIVE E.L.EACH ACCIDENT Is VO�'00e OFFiCER/MEMBER EXCLUDE D7 a NIA (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE s 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I s 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addltlonal Remarks Schedula,K more speoe Is required) PLUMBING CONTRACTOR.OWNER JASON THOMAS ELECTS TO BE EXCLUDED FROM WORKERS COMPENSATION COVERAGE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DTE THEREOF, NOTICE ILL BE DELIVERED IN TOWN OF ANDOVER ACCORDANCE WITH E POLICY PROVISIONS MASSACHUSETTS 01810 AUTHORIZEDREPRESr TATIVE I 1 88 009 ACO11121 RPORATION. All rights reserved. D! ACORD 25(20091091 The,CORD name and loco are reals ed marks ACOR I I ���COIIAMONWEALTH OF MA.SACHUSETT& BaA�o ,.two i PLUMBERS AtO f GASFjITTERS ISSUESTHE FOLtOWIz1G LICENSE �R IS >rRED AS;A` PLUMBIIJG DORP J(TRATIMEEXT ERP�I,SES LLC T#' 13 ,JACKMAN °RfiDG1$ AD ° 1 O.HAh � AIH 0308] 1670 ' r _ ...s 3442 `5/o 11 q 9 Lei I �` .��x!�OMMONWF„a►LTH=OFM�S CHl?S�TTS • • • • -; PLUMB R'S::: AND GrASF ITTEI S µ 1 t N � � ISSUES THE f�OLLOWING�LICE�NiSzE' $k{ �: . h4A$Tfk PLUM6 -TU .JASON' WTHOMAS 3 �r � r y r.o /xai f 16. i Date.. �. ......... 10663 TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING._ 88ACMU5� This certifies that................E........:................. ..!'Vw!..�J(? . ti!�U,J .... ..... has permission to perform..... � .....��'..xyvA l......................... plumbing in the buildings of....:........i......t.` '�`��:/A`.—se j........................... at......... �.. ''..!. -. ............... North Andover, Mass. FeeA..."..Lic. No. . !.... ........................................................... PLUMBING INSPECTOR Check# M �' 111 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ CITY _iVt/1XJU _ _ _ MA DATE 1_9T . _ PERMIT# lam(! 3 JOBSITE ADDRESS /_Y ._ gT OWNER'S NAME OWNER ADDRESS __ _ _ ___ ---- -- �� P —..—_ TEL ----_ IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL Q' PRINT CLEARLY NEW. RENOVATION:5— REPLACEMENT:Ej PLANS SUBMITTED: YES NO FIXTURES X FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _-.., ._; . CROSS CONNECTION DEVICE _ ► __ J .. I _I I _..._I __._ J DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM l ------ -- - I DEDICATED GREASE SYSTEM -- ._.__.-_I ( __I —.___1 _. _._I - _-- J _ _--_.I __-- DEDICATED GRAY WATER SYSTEM 3 .. — _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _._ ; ._.. _ —..__—. -------- FOOD ------FOOD DISPOSER __....I -_.._..--J ------- FLOOR/AREA .FLOOR/AREA DRAIN _ ._i . 1 --------- INTERCEPTOR _.-INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET 'VN\ RINAL WASHING MACHINE CONNECTI01 WATER HEATER ALL TYPES S ���� WATER PIPING OTHER --1 _..._. ...... ..-... .........._ - - r-�i -- -- - - ------ --- - - .._._. . G, 1 I have a current Ilablilly nsuran 1�2�I`-� \•�� luirements of MGL Ch.142. YES NO 1F YOU CHECKED YES,PLEASE IN 'RIATE BOX BELOW LIABILITY INSURANCE Pt BOND [ OWNER'S INSURANCE WAIVE[ ;e coverage required by Chapter 942 of the `-jr— Massachusetts General Laws, ,_.�..____.�_�_ _ is requirement. CHECK ONE ONLY: OWNER Q AGENT -_i 'S), SIGNATURE OF OWNER OR AGENT I 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 co ince with I P e rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 4071VOK_A_ A 5 V ...-._._.- -I LICENSE# /.25?02 SIGNATURE MP ET JP D CORPORATION[,—I# PARTNERSHIP El# LLC E3 COMPANY NAME L . ADDRESS -.-._-- ; CITY _--[� - ---- - - ...--------'STATE .. .- ------- ZIP _��P..� ... TEL (o Sld�......_..�.. : PIC /I .. _ . .._._ FAX i CELt EMAIL -- ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK , CITY -N -- ]X1 v _ _ _-- -- _ _ MA DATE -- / [- PERMIT# JOBSITE ADDRESS l_Y ._ _ t .g?_ _ OWNER'S NAME P OWNER ADDRESS -- -S� ------— -- — TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL[�]' PRINT CLEARLY NEW: RENOVATION:B- REPLACEMENT: PLANS SUBMITTED: YES NO[] FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ . ___-i .---_ { CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GASIOIUSAND SYSTEM -_ DEDICATED GREASE SYSTEM _— . . ..-I DEDICATED GRAY WATER SYSTEM ! DEDICATED WATER RECYCLE SYSTEM ! i DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR IAREA DRAIN I ---j INTERCEPTOR INTERIOR KITCHEN SINK __.._I _. _ __-. ► ___.J _J —� _-- (� LAVATORY _ ROOF DRAIN I --_--._ SHOWER STALL SERVICE I MOP SINK TOILET tRINA WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ____1 ____-....- .- ..-.- .____-1 _-- _ ...._.. -- i -- _ I J ! _-- -- 1 1U WATER PIPING OTHER ........................._... _______-.--.----._.-...1 -------...1 _J -- -I .._. _-. _.__...__I INSURANCE COVERAGE: I have a current E a Ilit Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[Rr NO ] IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .� LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITY �, BOND [ OWNER'S INSURANCE WAIVER:I am aware that the licensee dges 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. TT CHECK ONE ONLY: OWNER 0 AGENT [] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are 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 co nice with I P Me rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. PLUMBER'S NAME /42Tl+ki�C_./�l.- kfti5� Vy( 1 LICENSE# /.2$?0?j SIGNATURE MP[T JPEl CORPORATION #=PARTNERSHIPE3# LLGEY COMPANY NAME ADDRESS �— CITY STATE 21P �3Q�y_ TEL S!o(o S _ - --- -- FAX CELL E EMAIL ( - ��� �J/� H�»� i The Coma tanwearih o,f tt2assaeh.useus Department o,flndustrzccl.A celdats j • - O,f,face o,flnvestigateons 664 Washington Street Roston,.ltd 02111 V mass gov/ciza ' Workex$,Compensation bsigxxance. dayit:Bmiae-relCon.ft-actorsmiectriciang/Plu bexs A. heant Koxw. Please Print Jr oObly Name(3usinos1Organ1zatson11'n&1dtral}: Address: 2 t '-so/Id City/Sia��/gip: /VRS - �f* 0.30&2 Phan,9: �G3 �6 �O Are eyyouran.employer?Check the apPxoPx1at0]box: Tyke of project(xec�uixec�}: 1. I am a emploper with 4. []I am a general contractor and 6. New Onstraction F qmftplopees(fullandloxpartime).T havoRkedthe sub-contractors 2. am.a sola proprietor or partner- listed on the attached sheet. 7. �(Remodeling lave, These sub-contractors have 8. ❑Demolition ship and working forme in any capacity. workers'comp,insurance.working Building addition tN'o workers'comp.insurance 5. ❑We are a corporation and its 10 1]Electricalrepairs or additions officers have exercised.their , recluixed.� 11.. Plumbingre airs or additions 3.[� X am.a homeowner doing allwork right of exemption per MGL � p myself bio workers'comp. c.152,§1(4),andwehaveno 12.Q Roofxepairs instirancerecluixed.]� emplopees.ENO Workers, 13.�Oilier • comp.insurance reclalred.] .Anyapplicautthat checks box#imustaisafillouithese�fionbelbwshowingtheirwbrkers'compensationpolzcyinfomiafion. Homeownerswho sabmitfhisaffidavitindicating ieyfiiedoing allwofkandthen.Mreoutside contractors mustsnbn:tanew affidavitindieatiiigsuch. tContractors that checktbh box must attached an,additional sheet showingthe name of:the sub,-contactors andihekworkers'comp.policy information. farm an empfoyev that is providing ivorrkers'cornpellsadon Wumee fo-FrY employee Berox�i he olicy ancijo i site ira,faimation. Insurance CompanyName;. Policy#or 98J ins.L1G.#: Expiration.Date: lob Site Address: City�State/Zip: oftTaevtoxke s'coxmpensatzoxrpolleycleclarationpage(showing•thepolxcynumberan.dexpiration.date) Attach acopy p'ailuxe to secure coverage as xequixedunder Section 25A,ofMOL o.152 can lead to the imposition,of criminalpenalties of a fne up to$1,500.00 and/or one-year imprisonment,as well as civil penalizes in the form.of a STOP WORD 01.dDER.and a ane ofup to$250.00 a day against the violator. Be advised that a copy of thig statementmay be forwarded to the Office o£ Investigations of the DIA.for iilsurance coverage verification. X do liexeby ter& the pain dpenaldes of perjury that tite ire,formation provided above is true and cora eet, Si ature: Date: Phone 0 lsti3 �.6 Oficial use only. Do not write in 61s area,to be completed ry ciiy or town official. City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building)[)epartm.ent 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector f.Other - - - Information and Instructions Massachusetts General Laws chapter 152 requires alt employers to provideworkers'compensation for fheit•employees. Pursuant to this statute,an employee is defted as"...everyperson k the service of auothex umder any contract of bixe; express orimplied,oral orwxitten!, An e&TloygN defined as"an individual,partnership,associafion,corporation or other legal entity,or anytwo oxmoxe' ofthe toxegoing engaged in a joint enterprise,and includingfXie legal representatives ofa•deceased empIpyex,.or.the receiver or-frustee of an.individual partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house crouthegroundsorbuildingappurtenauttheretosb.allnotbe6auseofsuch ein loymezttbedeemedfobeanemployes." MGL chapter 152,§25C(6)also states that"every state or local lic-em mg agencyshall withhold the issuance or .renewal of a license or permit to operate a business or to construct buildings in the.comraonwealth.fox any applicant who has not pro dticed.acceptable evidence of compliance wlih the insurazlce coverage required., Additionally,I GL chapter 152,§25C(7)states"Neither fhe commonwealth nor any of its political subdiVisions sha11 enter into any confract fibr the performance ofpublic work-L til acceptable evidence of compliance with theinsurance requirements ofthis chapterhavebeenpresentedtatheconttactingauthorzfy." , N. .Applicants ti Please fi11 out the workers,comp ensailon affidavit completely,by checicng tho boxes that apply to your situation and,if ii6cessaty,supply sub-contractox(s)name(s),addresses)andphonenumber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)orLimited Liabilitypartnershi s p (LLP)Withno employees other than,the members oxpartuers,arenotrequixedto caxryworkers'compensation insurance. If anLLC orLLP doeshave employees,apolicyisxequixed. Be advisedthattbisafhdavitmaybesubmittedtotheDepartmentof'Tndrzstrial Accidents for confirmation ofinsurance coverage. Also be sure to sign and date the affidavit. 1'he affidavit shoutd b e returned to the city or town That the application for the permit or license is being reqaodoq,not the Dep artment of Industrial Accidents. Shouldyou have any questions regarding the Iaw or if you are requited to obtain a workers' compensafionpolicy,please call the Department at the number listed below. Self insured companies should enter(heir self insurance license number on the appropriate line. City or,Town Officials Pleasebe sure,thatthe affidavit is complete andprinted legibly. TheDepartm.enthas provided a space atthe bottom ofthe a1adavitfoxyouto fill out in the event the Office 0MV0stigationshas to contact you regarding t o applicant. Please be-sure to fill inthe permit/license number whichwill be used as a reference number. In addition,an applicant fhatmust submitmultiple permit/11cense applications in any givenyear,need only submit one affidavit indicating current PORGY infoxazation(ifnecessaty)and under"Yob Site Address"the applicant shouldwxife"all locations in (city or tow:n)."A copy o£the affidavit that has been officially stainped or marred by the city or town may be provided to fife applicant aspzoofthatavalidaffidavit•isonftteforfuturepermitsorlicenses, Anewaffidavitmustbof ledoutea(;h year.Where a home owner or citizen is obtaining a license oxpennit not related to any business or commercial venture Q.e,a dog license or permit to burn leaves eta.)said p exson 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 uestions, please do not:hesitate to give us a call. . q UwDe axtmeat'saddress telephone,1eh oneairdfaxnumbe x.• p - 'ho Camollta t o S as ac P 3?epa Gxxrextl Qflnd-ufthl e is Office d1imstfgaval' 6Q Wuhington Bogan, O211 x ` , 6xN2 �4Q�e 4q6 ax x-877-� � - Revised 5-26-OS Fax 617"727 774 i COMMONWEALTH OF MASSACHUSETTS Rl Lel e • • e o I Fill 0 10 161:4 BOARD Q.f I PLUMBERS. AND -GASFI..TTE#s: ISSUES THE FOLLOWING LICENSE,.;,::: L10E;NS D AS A MASTER PLUMBER /f Z ARTHUR H JOHNSON JR 21 BOLIC S.. >NaSH'uA ><:;:;tyH 03062-32 t 1257 05/01./ 6 207005 I i . I Date...... i o�NoarN4h TOWN OF NORTH ANDOVER * * PERMIT FOR WIRING s`4ACHU5� VV- Thiscertifies that ....Gf I............................................................................................ has permission to perform ....... ..... t p.f�,.r?.r.. .. ........................ wiring in the building of................ �.... 1................................................... —7 ... at . f / /�; -»... ..........:... rth Andover Mass. Fee:. ..'!T!.�.........Lic.No.`2 1.. ... /,T'..... ........... ELECTRICALINSPECTOR` 7-1 Check# .G • Commonwealth of Massachusetts Oe -use Only Permit No. " o Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank a APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C,5 CMR 12.00 a (PLEASE PRINT INMK OR TYPE ALL MFORMATIOA9 Date: City or Town of. NORTH ANDOVER To the Insp ct r of tiYires: By this application the undersigned gives notice Pf his or her intention to perform the electrical work described below. Location(Street&Number) ► � � Owner or Tenant ������S�YI Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) b Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: in*M JerY7 Oq e Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans TransTotal Trsformers KVA � No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones r— No.of Switches 3 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained p Totals: """ "" ""'................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent ---� No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: j No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. f 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 l undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSUR.ANCE ❑ BOND ❑ OTHER ❑ (Specify:) Xcertify,acnder the ains and nalties ofperjury,tl:at tlZe information on this application is true and complete. FIRM NAME: , � Gdl �' C 1,U A LIC.NO.: V/` —� Licensee: On Signature LIC.NO.:^ 1 (If applicable,en r ' xempt"in the license 4umber lined Bus.Tel.No. Address: .-cl G►/Y Ci Hui FCA - IJ14 dM11 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)❑owner ❑owner's agent. Owner/Agent 1 Signature Telephone No. PERMIT FEE. $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the ` t notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: r ***Note:Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: r SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: I ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ I Inspectors Co ents: Inspectors Signature: Date: FINAL INSP -TION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comment's: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): o V�"Y I 901, C- Address: City/State/Zip: (nC NJ1 Phone#: Gof 9/T Are you an employer?Check the appropriate box: Type of project(required): 1.( I am a employer with '5 4. ❑ I am a general contractor and I 6. [-1 New construction employees(fall and/or part-time).* have lured the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition 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.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions • myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurance �ired.re q ut employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 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 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 b6forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby cer!tW under ggyams and penalties ofperjury that the information provided bo a is true and correct. Signature: Data Phone#: 9 U U 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#: • r 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 ofhire,• 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 anherwho 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 p yment be deemed to be an employer. MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth o£.l-assa..chvsetts Department of Industrial Accidents Office ofInvestigations 6.00 Washington Street Boston}MA,02111 TeX,#617-727-4900 ext 406 or 1-877-MA.SSAFB Revised 5-26-05 Fax#617-727-7749 -www-Mass.govfdia r v COMMONWEALTH OF MASSACHUSETTS BOARD Of , lECTR I C'I ANS s ISSUES THE FOLLOWING LICENSE AS A REG JOURNEYMAN ELECTRICIAN 1° GARY< A FA_LLON 8 ROSEMARY HUDSON {GLH 03051-66T. 1213J:R 07/3,1/1b 1177 8 { r { Date. .. .... .... RTN 0 1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACMUSEtt This certifies that . . Aee4 .45 . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation 1r 40f . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . .A. . Nor.th, nd-o-ver, Mass. Fee.,?O.,.5�. Lic. No. . . . . . 1719 GAS INSPECTOR Check# 7834 . 1+ i� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:AV/' MA. Date: l� j I� Permit# C�Building Locationel�l 7 ZI�/y�YK Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ® Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES Cn Cd . Cn LU a N W v _ Cd 3° m = o WWL) CO o = WWF z � QQ Z >- W Z cn o 2 W w w w W m O ~ a H o W x_ J W ? cl, L) WW � Z � WNo Lu W � oxLL � Z W Ix N _J H F- O Z J U' LL lam. = W W W O � Q �' W W m > O Z O W Z Z W a H li\ U 0 U. (7 (7 x x O a F- > > > O ti SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR 5 FLOOR 6 TH FLOOR 7 TH FLOOR 8 TH FLOOR / T— Check One Only Certificate# Installing Company Name:A// �y�y,�r�.(��-�.. �p� j q ,G.�� ,,,, • r� ��;�f� ❑Corporation Address (/ f City/Town:���� State:j� / 1 ❑Partnership Business Tel:1.���/ OLS,-'—222� Fax: �Firm/Company Name of Licensed Plumber/Gas Fitter: / d INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes&L No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ez A&V4 Itle ®.Plumber Title ❑Gas Fitter Signature df Licensed PI as Fitter LiiAaster City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑LP Installer - c r COMMONWEALTH.O'F MASSACHUSETTS . LICENSED AS-A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: NEIL B ROSS 6 CHARLES ST P..EABODY MA 0.196.0-4214 15475 05/01/12 784768 3 1 _ 1 4 The Commonwealth ofMassachusetis Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 . ' www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslEIectricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): Address. r• City/State/Zip: ��> �v 0 (fi) Phone#: [Es an employer?Check a appropriate box: _ a em to erwith 4. [E - jt10 project(required):p y ❑ I am a general contractor and Iloyees(full and/or part-time).* have hired the sub-contractorsew construction a sole proprietor or partner- listed on the attached sheget. tmodeling and have no employees These sub-contractors have molitioning forme in any capacity. workers'comp,insurance. workers' comp,insurance 5. ❑ We are a corporation and itsilding additionred.] officers have exercised their ctrical repairs or additionsa homeowner doing all work right of exemption per MGL mbing repairs or additionslf [No workers'comp. c. 152,§1(4),and we have noance required.]r em to ees. of repairsp y [No workers'comp,insurance required.] er 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy anti job site information. Insurance Company Name: U %/4:� Policy#or Self-ins.Lie.#:__ �� �O� Expiration Date: Job Site Addres 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. J ry do hereby certify under flae pains and penal s ofP er'u that the infornzafion provided ah a is tr and correct. ;i nature: Date: /72 3 J `none#: Official use only. Do not sprite in this area,to be completed by city or town official. City or Town: Permit/Liceuse# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: . a Yl 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 j oint 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 buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers',compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to 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 Depaitment 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 pernrit/licerise 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 for any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affiddvit. 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: T ie COnni-Aowwea tdO 1`M�assaclill?setts Depar`rai e.,t of Industrial Accidents Office of 1nveSUgatioRS 600 Washington Street Boston,MA, 02111 Tel. #617-727•-4900 ext 4406 OT 1.-877-MASS.AFB P0.14-1 S O'C'„r, Fax#Fi 17.,797-77dQ VERYCIFICATE ORnn CERTIFICATE 4F LIABILITY INSURAN E DATE IMM/DD/YYYY) '-4t, 10/13/2011 RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TH CERTIFICATE HOLDER.THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE q FORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUIN 3(NSU ER(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 SUB OGATI N IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this ce ificate oes not confer rights to the certificate holder in lieu of such endorsement(s). CUNIAUI PRODUCER NAME: All Duffy Insurance Agency, Inc. a°N„ EMt: 781.593.1200 (FA/C. No;781.593.7260 317 Broadway �'ooREss: _ _ WyOIBa Square 1NsuRER(S)AFFORDING ;OVERAGE NAIO0 Lynn, MA 01904,2602 INSURERA: Safety Insuran a Co any 39454 INsuaeo A71 American P ulnbi ng and brains INSURER B; c/o Neill Ross INSURER C: _ 6 Charles Street INSURER D: M Peabody, MA 01960 INSURER E: ` INSURER F: COVERAGES CERTIFICATE NUMBER: 59 REV SION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER OOCUME T WITH 1ESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I SUBJE T TO ALL THE;TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR A001. TZ967TPF POLICY EXP LTR TYPE OF INSURANCE INSIR WVo POLICY NUMBER MM/DD/YYYY) MMIDD/YYYr LIMITS OENERAL LIABILITY BP0001145 12/15/2010 12/1512011 EACH OCCURR NCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREt IISES Ea occurrence) $ 100,000_ CLAIMS-MADE FX I OCCUR MED =XP(Any o ie person) $ 10,()00 A PER ONAL&A V INJURY S 1.000,000 GEN RAL AGGF EGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRO UCTS-C MPIOP AGG $ 2,000,000 POLICY F1 PRO-JECT 7 LOC $ AUTOMOBILE LIABILITY COW IINED SINCLE LIMIT _ Ee& Cltlenl $ ANY AUYO BODI Y INJURY Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS 60D1 Y INJURY Per eCCldenl) $ NON-OWNED $ HIRED AUTOS AUTOS Pet Cct0enl $ UMBRELLA LIAR OCCUR EACy OCCURR NCE $ EXCESS LIAB CLAIMS-MADE AGGi EGATE S DED I I RETENTION$u N $ ~ WORKERS COMPENSATION NC STAT --IOTFF AND EMPLOYERS'LIABILITY Y/N ORY UMI ER ANY PROPRIETOR/PARTNER/EXECUTIVE[::] E.L.E ACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA IMandatcry In NH) E.L.C ISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.I ISEASE-POLICY LIMIT $ I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additlonal Remarks Schedule,if more space Is required) Fhe Town of North Andover is also an additional insured CERTIFICATE HOLDER CANCELLATION FAX: 978.688.9542 SHOULD ANY OF THE ABOVE DESCRIBED P LICIES CIE CANCELLED BEFORE THE EXPIRATION DATE.THEREOF,NOTICE V ILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIOI S, AUTHOR R 137ATIVE Town of North Andover At n: Rick 1908-2010 ACORCORP RATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Locat d i n � r No. Date k, N°"T" TOWN OF NORTH ANDOVER �,:e ? •�' a QL-^ , p Certificate of Occupancy $ Building/Frame Permit Fee $ £�: ,SSACNUSEt Foundation Permit Fee $ Other Permit Fee $ aJ Sewer Connection Fee $ ` Water Connection Fee $ rV TOTAL $ Building/16spector 1 0 3 2 0 Div. Public Works ;t PERMMIT NO., �2- APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. .IMAE �O. ✓' LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ZONE SUB DIV. LOT NO. LOCATION RPOSE OPVW4b6iY&,.. / C. if c6`L� 5' OWNER'S NAME � °/ NO. OF STORIES / SIZE >/� OWNER'S ADDRE /'/7 /�.�/ I ��. BASEMENT OR SLAB ARCHITECT'S NAME ! —��l. SIZE OF FLOOR TIMBERS �IST• 2ND" 3RD BUILDER'S NAME Tok� SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY L,4S`ff'UILDING ALTERATION ye-.S— IS BUILDING ON SOLID OR FILLED LAND ILL BUILDING CONFORM TO REQUIREMENTS OF CODE �/ IS BUILDING CONNECTED TO TOWN WATER __-BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER v IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES -EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. GJV COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. -- SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS `PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILE Ael- BUILDING INSPECTOR SIGNURE OF OWNER OR AUTHORIZED AGENT,off ,Q - F E E L410 OWNER TEL.# PERMIT GRANTED CONTR.TEL.# 19 ONTR.LIC.# H.I.C.# - �v32- BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY _ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _ OFFICES ° LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a I 2 (3 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY MALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/1 % FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDD11 D _ ASBESTOS SIDING _ COMIACN VERT. SIDING ASPH.TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. 8 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BILK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR POOR ADEQUATE I-iNONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) A FL _ AT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 6 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS + 7 NO. OF ROOMS GAS OIL B'M'T2nd _ ELECTRIC , 1st 13rd NO HEATING Page No. of Pages PROPOSAL IoM aur�o� J & B ALUMINUM INC. �A c SVinyl Siding Screen Rooms v Windows 603-893-7005 Carpentry Fully Insured• 10 Years Experience •Free Estimate PHONE DATE PROPOSAL SUBMITTED TO y klill z1ar Cj W STREET JOB NAME C / �/j CITY,STATE AND ZIP CFE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: SC . cj- dcz WE PROPOSE hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: ILIe lF, ' dollars($ �� � !� )•. Payment to be made as follows: All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from above spec fica- Signature , tions involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents Note:This proposal may be or delays beyond our control.Owner to carry fire,tornado and othewr necessary insurance. days. Workmen's Compensation Insurance and Public Liability taken out with SLA�. ,1 '&ithdrawn by us if not accepted within ACCEPTANCE OF PROPOSAL—The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized This contract may be d in the first 3 working days atter acceptance. to do the work as specified..Payment wil be made s Outli above. Date of Acceptance: `�/w Signatur A HOME IMPROVEMENT CONTRACTOR Registration 122153 Type DB EzpirationA 07/26/981 JOHN BERTHOLD CONSTRUCTION s. John A. Berthold 15 Popular Rd ADMINISTRATOR =' Salem NH 03079 i I .. ... - ... .. - 3 N©RTtj F ToVM Of . over h a 19 � Zo � ,� � rt � dower, Mass., coc-CHEWICK A0RATE1) S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System DI —ai ' 9sm I7 BUILDING INSPECTOR THISCERTIFIES THAT....... �.M...... . ... . ... ..............� . ..... .................................... . .z Foundation has permission to~..... buildin on .........UV.17............. .. . .. ......�..�............................ Rough t0be OCCUPIed as .................... .. ..... ........................................................................................................... Chimney provided that the person accepting this permit sha n 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 relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough • PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI N STARTS ELECTRICAL INSPECTOR Rough .Gf... .:........ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR • Display in a Conspicuous Place on the Premises — Do Not Remove Fnagh No Lathing or Dry Wall To Be Done • Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. Location Na No. C CC( Date Y NORTp TOWN OF NORTH ANDOVER F � A a � Certificate of Occupancy $ Building/Frame Permit Fee $ 130 s,+cMust Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ A 4' Check # d q3 3 v 18631 �� �M-- Bu6cling Inspector r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT EMIRENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED. o2�f�f" /b —4- o S X SIGNATURE: l l Building CommissionerflngWor of Buildings Date SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 14'7 14 %G-►+ S T- ' 0 Co 7 , o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: f1 L Few Zoning District I r Use Lot Area Frontage R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided v 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT P,10 rn 2.1 Owner of Record ROiR>i u L4 Coe& ,2i+.1 Name(Print) Address for Service: Signature Telephone i. '7 (1 2.2 Owner of Recor NDlc 6 Name Print Address for Service: z Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construc tion Supervisor: Not Applicable ❑ � I Licensed Construction Supervisor: License Number P� Address Expiration Date Signature Telephone r � I' 3.2 Registered Home Improvement Contractor Not Applicable ❑ IL� ComNam p' L Z-� Sret P epY rn Registration Number Address J —0(—.> r z Expiration Date /1 Si naG) ture r 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 buildina Dermit. Signed affidavit Attached Yes....... No.......0 SECTION 5 Description of Pro sed Work cluck v a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: KEPL.,ACC 3 LAD SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed bpermit applicant 1. Building (a) Building Permit Fee i Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x tb> 2 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 ot'Owner Date SECTION 7b .OWNER/AUTHORIZED AGENT DECLARATION I � C" 4}t) as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are Lme and accurate,to the best of my knowledget and belief �kC14 t Print Name L ` ( , Si ature of Owner/Agent Date —1 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS Isr241) RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF,GMPERS` HEIGHT OF FOUNDATION THICKNESS r' SIZE OF FOOTING X MATERIAL OF CHININEY. IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i 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: (Location of Facility) Signature of Permit Applicant I I7 q-0 5 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I I AT-HOME Installed SIR S Siding and Windows Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:-_126893 EWIraf un 8!3!2006 Supplement Card THE Home Depoti.At o7ne Sern @UNROEUN CHHOUY yf�y 3200 COBB GALLERPA PKWY'#20 � ALTANTA,GA 30339 Administrator Proudly sold,furnished and installed by RMA Home Services,Inc.,a Home Depot authorized contractor. 345 Greenwood St. Unit 2•Worcester MA 01607•508-756-6686-Fax 508-756-2859•Toll Free 800-657-5182 FROM :, KIMBLY FAX ND. : 6033629679 Sep. 24 2005 11:17AN P4 I 10ME IMPROVEM VN I CONIRACF Sold,FLlrnlShedRnd 111511;edby' Branch Name: THD At-Hoil'v') ery'�:es, It,'C. d/b/a T�hel-lonie Depot At-Hume Serv:ces 345A(ireenwoo)d Street, Worcester,NIA()I OQ7 Branch Number! Job#! To!!Free(800)657-5182; Fax- 50>-756-22859 CTFciI lf)h 75-269134W .Moi I I L Y C:0,2419 Rl Cosa.!-,,!;16427 iQ#`i65522: MA Borne I rnprovcmcm Cowncto,Reg.11126991 Installation AddreSS: City State Zip Purl asst(s); Last 4 Nots of Driver's Lic.it&Exti.Mo/Yr; Work Phone: linnne 1111(at". Home Address: (If different from Installation Address) City State Zip Project Information: D"We/you("Purchaser".),the owners of the property located at the above instaiianonaddress,offer to contract with Fforne Depot US.A.,Inc ("Home Depot")to furnish,deliver and arrange for the i risiallarion of all rnaterials;;ls described on the attached Spec Sheet#: incorporated herein by reference and made a p;,r hereof home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to iii structural problem with the home or because work*required to complete(lie job was not included in the contract. DEPOSIT PAYMENT OPTIONS (SubitCCt to fund verification AnCilor Credit approval.) Check.Gasli,,�rs Check or US Postal Serv,"Money Order CONTRACT'AM 0 1 TNT $2� 1. (Made payar,lc to The Hoirc Dcipot) *LESS DEPOSIT S 2. Crcdit Car&andlor other payment options-Circle One Below Visa MasterCard Discover Arns,rican U\prcss BALANCE DUE ON COMPLETION $ 7he Home D�pci Honie 11"piovemael Ieiul ie Home Depoc Credit Available Credit:S/06(2)L (ml:&RD(-C.o"'i.Y) �*Minimum*Minimum25%of Contract Amount dueupon execution if this contract. Ac,14; 7 Exp.Datc: Name as it appears on card;__ _Q/1,) fi/,nr Indicate Payment Method For *By inylour itignaturo below,Vwaagtao to Allow Home Depot to cl—ge the above RA LANCE DUE ON COMPLETION: refemni;cd Cnnl f epos indicated.cated. ;5 HIL or HDCC Authorization Codes De posit Final Payment # L5_� -i#—Wa'9?� — Purchaser agrees that, immediately upon satisfactory completion of the work, Purchaser Will execute a Completion CrtifiQate and pay any balance dile. purchaser also/i igree,;to be jointly d 7an ' e all obligated d liable hereunder, AG Ent re A� m nt n alfCt its attachments including any financingagreement,con ata t c cornp ete agrpemen( UCIw en i , the parties and can not be arn icl,d or modified I attachments, in writing in a separate agreement si trazed by N,both parties, W't C CQ IV07r NACbE TO Do not sign this contract before you read 11. You are entitled to a completely filled-in copy of the contract at the titre you sign. Keep it to protect your rights. Do not sign an,,Completion Certificate or agreii,iniont stating,that you are satisfied with the clitilre pro-jeci before this project is cornpiete. Law prolifloitti home contractors from reluc.sting or accepting 4 Completion Cortificate%ign"J t I. by the ov%,)ltr prior to the actual completion of ;oirieto w,irk to be performed under t it contract. N ju may cancel this transaction at Any tinte prior to inidnighl of the third business day after the date of this contract. See`otic.. if Cancellation for an explanation of this ri;,hl. There willbea service charge equal to 25% of the contract ar-inni if the job is cancelled by Purchaser Ak'1'1,,IZ the third business day. BY MY-fOUR SIGNATURE BELOW,llw!;A01U.1 TO BE BOUND BY I III 11:10,15 OP THIS(__�()N' '''RAC I !Wl:ACKNOWLEDGE RF�CPtIlT OFA COPY OF THISCoNTR,-,,C7 AND I WO COMPLETED CONIS OF I']IF.NOTICE OF CANCEH.A I ioN. . BY MY/OUR SIGNATURE BELOW, I/WL UNDERSTAND THAT 1111. AORPRMENT IS SU3JI;(:l TO RFVIEW OF MY,'O[JR C-'REDI r HISTORY AND I/WE AUTHORIZE 1101VIl-,DEPOT AUTHORIZI:'!)CONTRACTOR.-10 VF'RIFv AND REvIEN& MY'O[.:R (-'REDI I RFCORD WITH AN INDi:PFN0EN'f CREDIT IZFPORTING AGENCY AND RFLEASE THEM FROM ALL LIABII.!']Y NCT)RIZED FROM INADVERTE;Tf 0MISSIC;NS OR ERRORS. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. SUBMITTED BY; Data: A PTED BY: CCE Date. -- Date: Homeowner NOTICE:ADDITIONAL TERMS,CONOTFIONSAND WARRANTILS ARE STATED ON rHE REVERW SIDE A_N 1)ARE FART OF I HIS CONTRACT white-Branch File YcJlo,v-Cmvr F1rk_Sa[cCva8vJljn1 5-17-05 C-SC /� 1 OW SPECIFICATIONSHEET e Spec. S et I` j Customer: _—T C)P\L'� S C! Sheet: of - ---- --- ---Job#:J7� Consultant:----1 rL (_ L- -------__ Date: Existing Window New Window 3 Measurements Grids Pattern' Pattern'sIt Pattern'Z r Winslow gHocations 3 Rough Opening o c w & Glass C,tray,Gorr,Location Style Metei Style . .Series o o °0 CCo oiL " y - ^ Options arden pcors(Room J Floor} "Code" Y1 N "Code" "Code" U Width Height U( >� L, _fl J > = J o 0_ "Code" ede,Ct tc Rtl S�� i''�r S 3 -L—M / lU) S{G LO. 7�� n 'Z -5 J e 1 r/ �. kj V1 !may r,1 j 3 a s s X z a a s m 6r 10 WU 0) RJ 11 lD G) 4—G,id Pattern and Location MUST be indicated- ' If a single ivindow or mulled windmis require multiple rid Color Of �9 p g patterns"indicate location and patlem in the additiortaf spaces ovided. < � � FcrCsmts,CpC,Bay or Bow,use"I.","W or"S"•(Stationary). For patio$Garden Doors,use"S"f8taiiona Window J Door Wraps BAY/BOW WINDOW GARDEN WINDOWS Projection Angle_ {bay:3"or 45') Top of Window to Soffit(inches) WALL THICKNESS` {inches) N ESeatbaaard Window Flan kers-UH l Csmt. � Width of Overhang(inches} SEATBOARD MATERIAL Material-Birch or Oak ff tied to Soffit,color of Soffit material lU Specify Birch or Oak Veneer or White Pionite .p New Interior Casing(BaylgowlGardervPatio_Doors a m Construct Roof '{Yes J No} Additional ctnrge for wall thickness of 6'cr more. Cianumhell(CL)or Colonia!iC0} There is no guaranteelhal new shingles will match existing color. // F have reviewed and agree with all of the SPE IAL CONSIDERATIONS: l!� (i� Cq /%� vim!q�C. 1- >+/ job specifications described above. J. .__04kA � ! L- `Customer S f urC Q i a QFC w=v,,i �4— Date San �i 6((Q,r IAORTH TO" 0 _ 4Andover o :;. rn �,o o * dover, Mass., J t @/"'It co r 3 Co C M ICMEWICK 7 AERATED P'P�\ BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System �� 6.1 .0 ' A BUILDING INSPECTOR THIS CERTIFIES THAT........ ...... ........................................................................ .. Foundation .............. .................. . ... .......... has permission to erect...... ? .................. buildings on ..1 99....! .......... Rough #0 be Occupied as r..A1^Cj M ..y.y�..........W low D..a.w.. ►........................... 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 relating to the Insp ction, Alteration and Construction of Buildings in the Town of North Andover. 6 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough y� '•.................................... Service B LDING 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 Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.