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HomeMy WebLinkAboutMiscellaneous - 15 WOODCHUCK LANE 4/30/2018r LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 December 17, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-5623 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845-5623 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: ERNEST H AND LILLY LIU LIN Loss Location: 15 WOODCHUCK LN NORTH ANDOVER, MA 01845-5623 Policy Number: PHOO100601960 Date of Loss: 02/15/2015 Cause of Loss: Water LA File Number: MA -2-30767 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Kris Kirkpatrick Adjuster LaMarche Associates, Inc. - 800-349-1525 Page l oft LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 December 17, 2015 ` Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-5623 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845-5623 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured; ERNEST H AND LILLY LIU LIN i Loss Location: 15 WOODCHUCK LN NORTH ANDOVER, MA 01845-5623 Policy Number: PHOO100601960 Date of Loss: 02/15/2015 Cause of Loss: Water LA File Number: MA -2-30767 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Kris Kirkpatrick Adjuster LaMarche Associates, Inc. - 800-349-1525 Page i of 1 LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 November 23, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-5623 w Board of Health/Board of Selectmen v NORTH ANDOVER, MA 01845-5623 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: ERNEST H AND LILLY LIU' LIN Loss Location: 15 WOODCHUCK LN NORTH ANDOVER, MA 01845-5623 Policy Number: PHOO100601960 Date of Loss: 11/20/2015 Cause of Loss: Water LA File Number: MA -2-30667 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Kris Kirkpatrick Adjuster LaMarche Associates, Inc. - 800-349-1525 Page 1 of 1 10.76? Date.... e. `� .... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING J -}-C, This certifies that.......�........................... . ..................... i�...............:..........:.....:........ has permission to perform ..........`.:...........................................................:............... plumbing in the buildings of....�i). iI.el?,—......................................................... at ... . �5...64)cark(` lP-Jt...... . 4..`.�............. North Andover, Mass. Fee.. -j ..... Lic. No. � apq..:.. t.!.........:......................:................:.........:... PLUMBING INSPECTOR Check #� • - -- --- -- - --- -- ---- --.---.--••_•, • •••- �•+..-•....r� U. ___u --.mumu uu� dpOlLe"Ll" die true ar)o_-accutale i0 {ne C� st of my knovAt!d and lh t all plumbing work and installations performed under the permit issued for this application will be in compliance vat ' I;P Ii e t rovision of t f4assachuselis Slate Plumbing Cade and Chapter 142 of the General Lav:s- �� �� PLUMBER'S NAh1E LICE f E 4 � �-� SI a, IRL 1 tIPJP ❑ CORPORATION PARTNERSHIP ❑ LLC ❑ ii COMPANY NAIAE � _ � ° � ��o :� _ ADDRESS _—���—� e' ' _r CITYSTATE°f `` ZIP (f;) k�15 TEL t �.tf FAX � , CELL =` _R9 � Ef.4AIL --" '[fit uvm r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK G ='! CITY MA MA DATE 2� i PERMIT JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TEL q28 (&r2-10CS FAX TYPE. OR OCCUPANCY TYPE COIAMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 0� PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT- I` PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR— asm 1 2 3 4 5 I 6 7 8 9 10 11 12 13 14 I� BATHTUB CROSS CONNECTION DEVICE } r } } C DEDICATED SPECIAL WASTE SYSTEM I (j DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM } } } DEDICATED GRAY WATER SYSTEM I } DEDICATED WATER RECYCLE SYSTEM , DISHWASHER I DRINKING FOUNTAIN ( G FOOD DISPOSER } FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY } } ROOF DRAIN I SHOWER STALL I } SERVICE / MOP SINK j TOILET } URINAL- VJASHING MACHINE CONNECTION— WATER HEATER ALL TYPES WATER PIPING OTHER 9 NAM I i IL " INSURANCE COVERAGE_ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.. 142. YES ` Q f•_l IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW S 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. CNF.Clt ONE ONLY: OWNER '—' AGENT ❑ SIGNATURE OF OWNER OR AGENT I h—h,, ro ;(.. rt ­r u .,( it— .i.,r • - -- --- -- - --- -- ---- --.---.--••_•, • •••- �•+..-•....r� U. ___u --.mumu uu� dpOlLe"Ll" die true ar)o_-accutale i0 {ne C� st of my knovAt!d and lh t all plumbing work and installations performed under the permit issued for this application will be in compliance vat ' I;P Ii e t rovision of t f4assachuselis Slate Plumbing Cade and Chapter 142 of the General Lav:s- �� �� PLUMBER'S NAh1E LICE f E 4 � �-� SI a, IRL 1 tIPJP ❑ CORPORATION PARTNERSHIP ❑ LLC ❑ ii COMPANY NAIAE � _ � ° � ��o :� _ ADDRESS _—���—� e' ' _r CITYSTATE°f `` ZIP (f;) k�15 TEL t �.tf FAX � , CELL =` _R9 � Ef.4AIL --" '[fit uvm r Date ............. .... ),.H ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ip T,;:,'--- certifies that .... .... ................. t ....................................................................... has permission for gas installation ..... L.r ......................................................... inthe buildings of ................................................................................... at .............. ........... . ................ North Andover, Mass. Fee.2 I ....... Lic. No. ....... ..................................................................... GASINSPECTOR Check # -3 n � 1. 9552 FIREPLACE __ -1 L-A.- � . . . . . . . L-JIL-A L-AL-AL�JL_D FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUPAIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER -Al ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER f WATER HEATER OTHER F ........ . .. ........... . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO 1 IF Y6u CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE_ECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY Lj'-' OTHER TYPE 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 [fj- '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 accurat to he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be 1 ern - ia e 11 e ent provision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE"I TURE MMS EjI JP 0 JGF LPGI [11 CORPORATION)kk= PARTNERSHIP 0#L ILLC Of# COMPANY NAME: ]ADDRESS CITY STATE ZIP ]TEL FAXlla CELL ]EMAILe L:�: I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lug CITY I - 2 - M. . - MA DATE ZS 1 y PERMIT JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS L= --Ji TE (C6516C FAX TYPE OR �'PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: El REPLACEMENTRU, - PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS- HIM' 1 2 3 4 5 6 7 9 10 11 12 13 14 BOILER BOOSTER d8 CONVERSION BURNER _j COOK STOVE ........ . . DIRECT VENT HEATER DRYER FIREPLACE __ -1 L-A.- � . . . . . . . L-JIL-A L-AL-AL�JL_D FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUPAIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER -Al ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER f WATER HEATER OTHER F ........ . .. ........... . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO 1 IF Y6u CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE_ECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY Lj'-' OTHER TYPE 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 [fj- '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 accurat to he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be 1 ern - ia e 11 e ent provision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE"I TURE MMS EjI JP 0 JGF LPGI [11 CORPORATION)kk= PARTNERSHIP 0#L ILLC Of# COMPANY NAME: ]ADDRESS CITY STATE ZIP ]TEL FAXlla CELL ]EMAILe L:�: I H O 0 N U W a w \ r, o rl z W >- � W LLI H U W a Z w � Q w a a w w w Cl) a 0 a a a J H a Q 6g h W S W i- LL k z° z 0 H U a c�7 c�7 The Commonwealth ofMassachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name (Business/Organization/Individual): cam — Address: City/State/Zip: Phone #: Are u an employer? Check the appropriate box: Type of project (required): Are a employer with 4. F1 am a general contractor and I 6. E] New construction employees (full an or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. F1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi 4%Wmpra*( penalties ofperjury that the information provided apove is trur and correct. 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 Informati®n 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 another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston} M. 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.Mass,govfdia ,i 10 R D FOR D_3_-'% MA 01835 779 17-::,6:4::*�5/0l/16 223373 y Date .. 7l is .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..( � .. - � ..�, //- ............. has permission for gas installation ................ . in the buildings of .... �e .. ............... '............. . at .. ob. ..mac w,c , % ............ ... , North Andovei, Mass. Fee �?I .. Lic. No.//.%AI/.. GASINSPECTOR Check # � 8781 3 f1v- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATEi PERMIT # CJ JOBSITE ADDRESS OWNER'S NAME L_— - -- GOWNERADDRESS -- TE V •(064 FAX TYPE OR PRINT E COMMERCIAL E] EDUCATIONAL ®RESIDENTIAL OCCU;�:OVATION: CLEARLY NEW: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES Q NO APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I -_... ._ ._1 . . I l LI. _ I .. 1 .. .. . Lj_ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER - FIREPLACE FRYOLATOR FURNACEr- GENERATOR-1 _ _-.1 GRILLE -- _l -----(_ .-_._ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT --A _m OVEN POOL HEATER ROOM / SPACE HEATER�-- ROOF TOP UNIT TEST UNIT HEATER- UNVENTED ROOM HEATER WATER HEATER OTHER -- -J---I'-- INSURANCE COVERAGE 1 have liability insurance its the MGL. Ch. 142 YESNO ❑ a current policy or substantial equivalent which meets requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[_! OTHER TYPE INDEMNITY ®! BOND I_ 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: QWNER E] AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this applicati are tr nd acc r to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will, be ' com n w II inent provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER -G FITTER NAME T �ll LICENSE # _`��eK I SIGNATURE MP MGF_ ( JP __:� JGF __I LPGI __! CORPORATION __J # ( PARTNERSHIP ❑# _-__.- _ _ LLC# -_„-_. _____J ❑ ❑ ❑ ❑ COMPANY NAME: cis -Y I- ADDRESS CITY...__..__j STATE ZIP �-j TEL - - -6' FAX CELL . EMAIL ._._-- - .._._-, _-- % , X \ k x 901 f1v- W H z° z 0 F U W a w z� O y� w � � W O� a LLIZ W 5 aLLI W w C0 �a d o a a a �C U F+1 J F., a a a � cn w s w � w W H O z z o � U x . a 0 c The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 to www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne (Business/Organizatio0ndividual): d' Address: City/State/Zip: i Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. # �• E] Remodeling 2. ❑ I am a sole proprietor or partner - ship and'have no employees These sub -contractors have 8. E]Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g• ❑ Building addition [No workers' comp. insurance officers have exercised their 10. El Electrical repairs or additions required.] 3. El am a homeowner doing all work right of exemption per MGL g p p 11.[]lu nbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] it employees. [No workers' 13. [i Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 't 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 and penalties of perjury that the information provided abTve is true and correct. 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 Instructl®ns 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 -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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department ofIndustrlal .Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax # 617-727-7749 vvwwaxxass,govldia Location 15 No. —37& Date c3 N°"r" o TOWN OF NORTH ANDOVER. 3?o' t"• ' •,��0 F ; Certificate of Occupancy $ S� ro ,' . ,Building/Frame Permit Fee $ SS' �ss�cHust�� ` foundation Permit Fee $ �G bihar Permit Fee ibex--> $ n cs Ai; 80Wer,Connection FeeTO $ Wit f..Qonnection Fee $ TOT' � i- $ / 3 O f Building Inspector Div. 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CO) C a� � .� L CD v o o CL CL cm< c c ev ca J -C 0 0 Z CD Q y C �f2e "V O��iC'GQ,66Gr�;�� HOME IMPROVEMENT CONTRACTORS REGISTRATION oard of Building Regulations and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 114228 Expiration 08/16/95 Type - PRIVAI"E CORPORATION (e*\ OL�a„�..�,a��G(.,�% HOME IMPROVEMENT CONTRACTOR Registration 114228 WOOD COMPONENTS WILLIAM H. STROUT 120 MAIN ST ADMINISTRATOR NO READING MA 01864 WOOD COMPONENI"S WILLIAM H. STROUT 120 MAIN ST NO READING MA 01864 r _ Type.- PRIVATE CORPORATION Expiration 08/16/95 ------- Title held with applicant Signature of applicant or applican s representative .._.__ .... tlnn in this anoltcation constitutes grounds for suspension or revocation of the appdcanis' registrplion 1 Fslisritoposssssacarrsat B-j""Am COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY _ PLACE AtassaabtrssttsStau Cods Isenv"forrsrooaNOn Usasss. ONE ASHBORTON ofthis OF 19f, MASSACHUSETTS I BOSTON, MA 02108 L %CENSE CAUTION Q. SUPERVISOR EXPIRATION DATE FOR PROTECTION AGAINS 07 / 2 5 / 19 9 5 EFFECTIVE DATE LIC -N0. THEFT, PUT RIGHT THUME PRINT IN APPROPRIATE RESTRICTIONS c 41 r 06/30/1993 0 0$ 0 21 o BOX ON LICENSE. NONE WILLIAM H STROUT Z BLASTING OPERATORS cz 1 ^ WOODCHUCK LANE >;i )RTH ANDUVE? MA n1845 T MUS�INCL pEPH1T1J• SS b 013-32-6225 R oNLn FEE. nFT a 1J"•i10 ti CErJSEF W" 'rFFIC1A_'.y .':, VALID UN TIL SIGNED BLI ti A6nRE❑ OR SIGNATURE OF 7HECOn.!Al SSIONER JUL �. 1993 „r HEIGHT: DOB: a '�� J 7 µ 1 C7/25 , « SIGNN1 FULL AtlI�ATU C] THIS DOCUMENT MUST BE ATIP OF LI EIE I ! , CARRIED.^,N THE. oEPq,,N(:r THE �.0'.. ^c,.VHE'a E': SOC GI;Rpn:^., „. MISSIONS R ^TH ERc, .:C;HT i.n;.r,E; ?RIN' ! ,AGECIN` W013326225 07-23-97 2 B 07-25-45 M DM H is ,01 9'rRCIUT WILLIAM H 10 WOODCHUCK LN N ANDOVER MA ` 01843-5622- FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** WOOL C,o APPLICANT: u.�OO tC)OnnenPhone LOCATION: Assessor's Map Number Parcel t` Subdivision olleA rare n �W() Lot(s) V Street -IS "tJ aubk LAS St. Number ************************Official Use Only************************ RECOM11ENDATIONS OF TOWN AGENTS: Z�,� b;��—, Date Approved Conservation Administrator Date Rejected Comments Date .Approved Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected v _"4, _) Date Approved Septic Inspector -Health Date Rejected Comments MtGC/L` ON 51961AIA Public Works ­sewer/water connections - driveway permit Fire Department Received by Building Inspector Date OFFICES OF: TOw_© - ' 120 Main Street ° : NORTH ANDOVER North Andover. APPEALS i, N Massachusetts o 1845 BUILDING ;. DIVISION OF". (6 1 71 685 4775 CONSERVATION , HEALTH PLANNING & COMMUNITY` DEVELOPMENT PLANNING KAREN H.P. NELSON, DIRECTOR r In accordance with the provisions of MGL c 40, S 54, a.* condition of Building Permit Number I Co 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 111, S 150A. The debris will be disposed of in: (Location of :Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Wood Components, Inc. yti ,• ars a� ra 11 i BUYER: HR. MRS. ERN1E LIM 15 VOODCH= LANE NORTH AIiDMU, lm 01845 PRWECP- 14 FT R 14 FT SCREMMVAIDDITICK 6 FT R 14 FT DE X AREA r ANWst 7, 1993 120 Main Street North Reading, Massachusetts 01864 (508) 664-4462 FAX (508) 664-6829 Wood Components, Inc. Name Mr and Mrs Ernie Linn Ph.Res. 508-794-9899 Bus. Address 15 Woodchuck Lane City North Andover State MA Zip 01845 I/we, the owners of the premises described below, hereinafter referred to as "Purchaser" offer to contract with WOOD C09ON34TS, INC., hereinafter referred to as "Contractor", to furnish, to deliver and arrange for installation of all materials necessary to improve the premises located at 15 WOODCHUCK LANE NUM ANDUVER MA 01845 according to the following specifications: 'cn y) (STATE) (ZIP) SF1E C XF=GAT=ONS WOOD COMPC[VEhTPS, INC. approved materials will be furnished and installed to these specifications: *Removal of old back porch and stairs (approximately 14' x 14' Deck) For rear of customers house *Build a 14' g 14' Custom Post and Beam Screenroan/Addition, with a Gable Roof line; Room to consist of the following: *Laminated Post and Beams with a Laminated center ledger, Beams approximately 3'-6" o.c. *Fix present sliding door unit in kitchen and lockset on exterior door in rear *Install one hinged style patio unit 6/0 x 6/8 with screens at Gable end of roan - *Install one hinged style patio door on right side of addition 6/0 x 6/8 *Three (3) Double -hung style window w/screens (2 in gable -end, 1 on right side) *Three (3) Casement style windows w/screens on left side *Floor area to be constructed on a wood frame Deck system of 2 x 10's 16" o.c. with one (1) layer of 3/4" T & G Plywood *Roofing Deck to be (1) layer of wooden pine Boards, Plywood and roofing shingles. *Deck Areas approximately 6ft x 14 ft each *Under Deck area to be enclosed with lattice panels at each end 120 Main Street 0 North Reading, Massachusetts 01864 (508) 664-4462 FAX (508) 664-6829 Wood Components, Inc. Buyer agrees to pay the sum of $ Eight thousand two hundred dollars 1st Payment 1/4 $ 2,050.00 2nd Payment upon completion of $ 2,050.00 Floor Framing $ 2,050.00 3rd Payment upon caapletion of Roofing Balance payable upon caopletion $ 2,050.00 TOTAL $ 8,200.00 WOOD COMPONEMTS, INC. BUYER UNLESS OTHERWISE SPECIFIED, IT IS UNDER. MD THAT THE OWNER IS READY FOE. THIS WORK TO BEGIN. THE PURCHASE PRICE QWTED ABOVE WILL BE MiORM ONLY UNTIL, (DATE) IN THE EVENT THIS OFFER TO CONTRACT IS NOT ACCWM BY CONTRACTOR, ANY PAYMENT MADE SER SHALL BE REMOED TO THE PURCHASER(S) AND THIS PROPOSAL SHALL BE NULL .AND VOID AND OF NO EFFECT. ONTRACTOR IS NOT RESPCNSIUE FOR EXISTING STRUCTURAL DEF1=S, DRY ROT, CODE VIOLATIONS OR UNDISCLOSED CONDITIONS. O REPAIRING, PLASTERING, CARPENTRY OR DECORATING IS INCT,ITDED UNLESS SPECIFICALLY CHARGED FOR AND SPECIFIED IN iRITING.HEREIN. ANY AND ALL ADDITIONAL WORK NOT MRMONED AND COVERED IN THIS CONTRACT IS SUBJECT TO AN HOURLY RATE OF $30.00 PER HOUR, PER MAN AND COST OF ADDITIONAL MATERIALS. CONTRACTOR TO BE AVOWED REAMNABLE ACCESS MEANS FOR Dom' AND TRUCK TO SITE AREA, WITH NORMAL CONSTRUCTION DEPRAVATION ALLOWED. 120 Main Street North Reading, Massachusetts 01864 (508) 664-4462 FAX (508) 664-6829 y ; Wood Components, Inc. 120 MAIN STREET NORTH READING, MASSACHUSETTS 01864 (508) 664-4462 Fax (508) 664-6829 'PWAME-P WALL 'STUD WALL W/ .4W&ATUIUG FiWisu SUEATWIN(7 VKTICAL, P012120NTAL SIDING STOPPED ABOVE DE-CICING 1.1---000TIWU0U4 �-LAQ41QO Ft?oM UQDE-P SIbIWG To KERF IU JOISTS J -x 0.. q" OFK DECKING11-1 0. KERF IN BECK �.C> JoISTs F -OR FLAGWP& DI21P P T'.'LEDGER BOLTED To KAMING JOIST NAQ&E-R -RA56ET SASE OF LEDGFI? ro COVER (;IbIIJG 2E FLAGW OVER ejt)jWG. IuTEt21OR FLOOP ,;7eucTIJI2E POOFI UG ROOF-;W&ATUIWc BLOCKING AG PE SPACE FOR V�IJ1 Z x 4OFFIr JOIN TO RAFTERG courluuous s( ExrERlow PLYw OTUEIZ EXTE-IZIC FIUION COWTIuuou; VEUT W/ TRIM s courluuous L F,OR SOFFIT JC Wood Components, Inc. a:xkos PT. s Approval Approval t Date LAP PLAGUING W/ M0I4TURE BARRIER POOFIWG (Nor LAP FLASNIIJG WALL FIUISu SuOWW) LAPS W/ Mol4rut?E (NOT-GWoWW). GIDEWALLOa I5AR0IC-I2 # STEP FLASNIIJG. WALL Flul4u LEVEL WALL (Nor-awoWN)• FLASNIUG see i59 D WOTCNED FOR 4TEP OR / ` .SIDEWALL FLA4U I NG 1a p`� 00� RIDGE SuiNGLEO MADE FROM EXTEND FIELD X40 I/S OF FIELD GWWOLE SUIQGLK 70 - / FOLDED OVER RIDGE 4 G?IDGE. NOEXPOSEp 5 Iu. OR SAME m6rToM ETE. DGgc, ~ Ra TE NG 49 FIELD Su I UGLES OF FLASNIUG6 VERrIGAL LEG OF (NOr LAP RGipFIUG. STEP OR 41DEWALL SLJOWN) FLASUIWe EXTENDS LAPS bIRECTIOP OF 4TEPOR StDEWALL FLA4NIIJG LAPS BE -LOW COaUER, SIDEWALL PREVAI LIWO WIND � s AS ALLOWED 6Y OR SrEP WALL FLASuING. 51bING. FLASKING• \DOUBLE WRAP STARTER UWDEaLAYME SWIWGLC-S OVEI2.R,IDGE CODES IU COLD CLIMATE4 OFTEW PWU112E A gTAI2rw STRIP OF BIruMIWOUG WATERPROOFIW& • I.B. FELT UWDEI?LAYML-Vr 4 UAILro PER SKIWGLE LAPPED OVER EAVE - LOCATED ABOVE4LOT4 FLA4WIWe INDENTATIONS DRI P EDGE LAPSr o UWDE-PLAYMC-WT ID RAKE. ' s' RAKrEF AgNIUG TWII2D COURSE STAI?TG W/ FULL 4NINGLE STA RTE•t2 COURSE W/ MIIJUS OWE TAI3, r TABS GUT OFF r0 6E OFKET 0 IN . SECoWD COURSE STARTS W/ FULL EAVE FLASUIWG 4WIUGLE MINUS I/z TAB. FI RST COURSE SrARTG W/ FULL 41.1I1JGLE. j ♦r , Jif % ... .h. }' \ \\ ' \�, � \ � 1 ____•�--� r, / � - i � � / i //,ice \ � \\ � / � / / \ i � � ,\ . n _...-� / � � /ice/ � .�/ ,� � , f �%� / ,. ,� �, i / �� � J % , //�. f \ � _ � .a � � __ \�, � '- - . � --� � --"``� %_ \,\ I � � ���� � / ; l �. f � o ��, � , � � . ,..�