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Miscellaneous - 16 LINCOLN STREET 4/30/2018 (3)
16 LINCOLN STREET 210/070.0-0037-0000.0 - - F Date.`�..._.... ?. .. . ...... . . NORTH pf „ao , 6.'40 o� °� TOWN OF NORTH ANDOVER o PERMIT FOR GAS INSTALLATION �9S SACHUSES�y le 6 S r This certifies that . . . . . . . . . / has permission for gas installation ... .. . . . . . . in the buildings of . S7e<<S at . . . North Andover, Mass. -- / . Fee. S`!�. Lic. No. 7`..... . . ... . . . . . . . . ti r j. . . . GAS INSPECTOR Check 8171 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ` UOP,18 �� ORK , Mass. �.-�Date S 4 Z Permit # Building LocatiI�'�onylb L( (JCOLI�� li owner's Name JOSM MLlA " l ►�_A���y 1e , �l-� Type of Occupancy Z.FAMIL� New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ W W W W W Y Z WW cc W to Z 'n o a w ►- a � z= o r w z Q m W ►- �� M o o c ms F- a W Qtu U) cc w = v W = W W Q a o. a > W N W W W J Q Z M MGcc W h W h X C7 F. Z J h Z r., W W O > LL }- U J W QW 0: W j Z, a W W z O z a O �y Z 0: ',S O t7 5 U. a O d J U cc Y p a F- O I ' S 116-6 S MT. I BASEMENT Z IST FLOOR 2ND FLOOR CC) 3RD FLOOR oo oo 4TH FLOOR "•� {A STH FLOOR 06THFLOOR 00 TTHFLOOR e STH FLOOR T Installing Company Name COLUMBIA (;aS GF MASSACHU56TTS Check one: Certificate # Address 55 MARSTON STREET XJ Corporation 1862 LAWRENCE, MA 018 41 - 2312 ❑ Partnership Business Telephone 9 7 8-691- 640 6 ❑ Firm/Co. I Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked yes, please Indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement.- Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and accurAte to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Gene s. T e of license: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 374'JT City/Town Journeyman —` APPROVED O FILE SE ONLY i BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FES i NO. APPLICATION FOR PERMIT TO DO GASFITTING i NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED C k DATE _19 GAS INSPECTOR i Location /f- f 7 /wC aAJ S 7` No. d 7 Date 31119 Z 01 "ORT" TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ,.t ` t Other Permit Fee $ ?-e) i ' f Sewer Connection Fee $ r r) Water Connection Fee, $ 1 ',TOTAL $ Z4• �-ca `Building Inspector 1 �. 5 0 Div. Public Works PEAJIIT NO. F)!V 7 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP K40. I LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK IPAGE - ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING �"' y - (L� OWNER'S NAME - a S, NO. OF STORIES SIZE OWNER'S ADDRESS y�,1 n ,�„1 p BASEMENT OR SLAB —_ ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME CkQ_ 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 IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO IiEQLPIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER 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 Q. FT.. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM 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 FILED_ 2 — V —/ a BOARD OF HEALTH SIGNATU E�O�F OWNER R A TH RIZED AGENT OWNER TEL.# F E E IV CONTR.TEL.# _.112 _._Q._ CONTR.LIC.# PLANNING BOARD PERMIT G N D 19 BOARD OF SELECTMEN BU NO INSPECTOR 1 BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY rOFCF IES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY CES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS, WITH PORCHES, GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE Bl.K. PINE BRICK OR STONE HARDW D PIERS PLASTER � _ DRY VJAIL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T AREA _ 114 1/2 114 FIN. ATTIC AREA _ NO 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 HARDVJ'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR IJ POOR ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING II 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 GAS 7 NO. OF ROOMS OIL B'M'A 2nd _ ELECTRIC 1st 13rd I NO HEATING ,ORTM OF •11• ,`� 3r.''..,, OFFICES OF: . o m Town of 120 Main Street APPEALS NORTH ANDOVER North Andover, BUILIANG, ;, .0 Mi1SSM-11LISCIIS c)1845 CONSEzRVA"11ON . ss"`" �`4 DIVISION OF (61 7)G85-4775 HEAL"I•ll 6! PLANNING PLANNING & COMMUNITY DEVELOPMENT KAIZEN H.P. NELSON, DIRECI.OR t s. i; ii f' 1 X11I iS In accordance with the provisions of MGL c 40 S 54 a condition of Building Permit Number © � is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 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. QN sr'�C QIF to l rc f,; �� - HN " ■ ���d�t� g own of 6 �0 ndover No. 047 O ti :ar1 �. .,4 DRISWAY ENTP1Y PERMIT — K� � er, Mass 19%z C ME WICK oR Pa. 9` PARD OF HEALTH PERMIT LD THIS CERTIFIES THAT.. ......... ......................................... BUILDING INSPECTOR has permission to erec .+�/! . buildi s on *40*4D�1 G. Rough •• � Chimney tobe occupied as..... ........ .............................................................. Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES I ONTHS ELECTRICAL INSPECTOR Rough UNLESS CONS UCTI STARTS Service Final . .. . . . . . . . ...... . ............... BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Pre s FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and App ved by Smoke Det. Building Inspector MAUSACHUSETTS�UNIFORM�APPLIC (Print or Type) ATION FOR PERMIT TO DO QASFITTINC3Y'�' Lr NORTH ANDOVER .. Mass. Date ! a_i 9 �(� ��t i Building �I Location �.,( � °.c�Vl Perm- #_ 90/ /� Owner's Name New ❑ Renovation ❑ Replacement plans Submitted: Yes ❑ No J I - N a u s a; w w O1J IJI ft h Y F a p H y x O ppy ~ < $6 = s O h °C x Tr ! b N F I U a O a O x w 3. N a N ° u r x = H h O r ai a/ N J = x d 9 1 « j .4 } Z q I IN w F !- w O a, �C J • sue—BSMT. , SAS MINT 1ST FLOOR 2ND,FLOOR I SAID FLOOR 4TH FLOOR dTHFLOOR I } GTN FLOOR l i 7tH FLOOR STH FLOOR ; Installing Company Name , Check one: Certificate Address S Q1 Corp.Partnership Business Telephone 3 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter lltlM 1 `�y INSURANCE COVERAGE: I have a current liability Insurancepolicy or Its substantial equivalent. Yes c❑one If You have checked yes, please Indicate theNo o type coverage by checking the appropriate bbox. A liability Insurance policy p Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does Chaptnot have the Insurance coverage required by er 42 of the Mass. General ws, t my signature on this permit application waives this requirement. Check one: n urs o or or pruner nt Owner IQ Agent O hereby certify that all of the details and information I have submitted(or entered)M above application knowledge and that an plumbing work and Installations performed under the permit I sued top pt is n are true and accurate to the best of my P�nent provisions of the Massachusetts State Oes Code and Chapter 142 of the aPPllcallon will In compliance vrl(h all �Y wa. type of License: Ttib Plumber sfil Gef gna ure o cense um at or as or City/Town Master License Number 1 �/3 Journeyman APPFX VED(OFFICE USE ONLY) Date HORTIy _ TOWNi0 -A TH ANDOVER �f tT�ED rb q�� A rl 3a y° OL 'r��,, o A PARMIi/4OR/ GA TALLATION • 4 . 'ts pOq�re°.P°y.�5 01kQ. �SSACHUSE� This certifies that . . . . . . . . . . . . . . . . . . has permission for gas installation .'7"1�iu4 . . . r,. .! in the buildings of . . . . . . . :%r. ::r.!`. '. . ' r�. .. ... . . . . . . . . . . . /(' j ,��, sT:;r` at �. t:�. . .1n. . . . .�. . . . ., North Andover, Massa Lic. GAS INSPECTOR f WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File STELLA - 16/18 LINCOLN ST. - i . f r t March 5, 1992 � w Joseph & Rita Stella OQ) 104 Meadow LaneNorth Andover, MA le Re: 16-18 Lincoln Street Dear Mr. & Mrs. Stella: All indications are that you have proceeded to construct an apartment on the third floor of subject dwelling, permission for which was denied by the Board of Appeals in its decision dated August 16, 1988, Petition #7-89. I hereby request that you make an appointment to meet with me so that I may inspect the premises in question in order to determine the extent of the violation. Your immediate attention to this matter is imperative. Yours truly, e D. Robert Nicetta, Building Inspector DRN: b g c/K. Nelson, Dir. 1a C3 ca N0RT1� ..� OF N 70 SSACHUSS TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS **************************** * Joseph & Rita Stella * Petition #7-89 * 16-18 Lincoln St. N. Andover, MA 01845 * DECISION * The Board of Appeals held a public hearing on Tuesday evening, August 9, 1988 upon the application of Joseph & Rita Stella requesting a Special Permit from the requirements of Section 4, Paragraph 4.122 of the Zoning ByLaws so as to permit expansion of the third floor into an apartment, making this a three (3) family dwelling. The following members were present and voting: Frank Serio, Jr. Chairman, Augustine Nickerson, Clerk, William Sullivan, Anna O'Connor and Louis Rissin. The hearing was advertised in the North Andover Citizen on July 21 and July 28, 1988 and all abutters were notified by regular mail. Upon a motion made by Mr. Rissin and seconded by Mr. Nickerson, the Board voted, unanimously, to DENY the Special Permit as requested, and the Building Inspector will be notified of the possibility of a violation of the Zoning Bylaw. The Board finds that the petitioner has not satisfied the provisions of Section 10, Paragraph 10.3 of the Zoning Bylaws and the granting of this Special Permit would derogate from the intent and purposes of the Zoning Bylaws. The Board also finds that the neighborhood consists predominately of single and two-family homes and that the addition of a three-family home in the area would adversely impact on the sere Y P serenity of this old established neighborhood. BOARD OF APPEALS Frank Serio, Jr. Chairman Dated this 16th day of August, 1988. /awt ,.-- T I SENDER: I also wish to receive the • Complete items 1 and/or 2 for additional services. • Complete items 3,and 4a&b. following services (for an extra • Print your name and address on the reverse of this form so that we can fee): return this card to you. • Attach this form to the front of the mailpiece,or on the back if space 1. ❑ Addressee's Address does not permit. • Write"Return Receipt Requested"on the mailpiece below the article number. 2. ❑ Restricted Delivery • The Return Receipt Fee will provide you the signature of the person delivere to and the date of delivery. Consult postmaster for fee. 3. Article Addressed to: 4a. Article Number Jam' a J �7-� 4b. Service Type li 1,,C ❑ Registered ❑ Insured i1n { 'Q Certified ❑ COD f -!. ��� ❑ Express Mail ❑ Return Receipt for Merchandise 7. Date�Delivery 5. Signature (Addressee) 8. Addressee's Address(Only if requested and fee is paid) 6. Sign a (Agent) 9 PS W&m-381 1, November 1990 *U.S.G O: —287-088 DOMESTIC RETURN RECEIPT UNITED STATES POSTAL SERVI(;E. Official Business - :;•;is• r PENALTY FOR PRIVATE USE, $300 1 Print your name, address and ZIP Code here i•L� i��C� L 7.7 )-f P 290 099 212 RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL " (See Reverse) " S " Senwe- " Jas N rn ifjLa— Street and No. 1 a P.O.,St and ode (� d wL4 XA Postage S Certified Fee Special Delivery Fee 'i Restricted Delivery Fee Return Receipt showing to whom and Date Delivered N Return Receipt sho g=to whom, Date,and Addr of`D ylivefX� ry TOTAL Pos ge' Fee77 0 Postmark or:64e E LL 0 a � — STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES.(see front) 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier. (no extra charge) 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the froniof the article by means of the gummed ends it space per- mits.Otherwise,affix to back of article. Endorse front of agicle RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6. Save this receipt and present it if you make inquiry. *u.S.c.Po.1989-234-555 KAREN H.P.NELSON °:t Town Of 120 Main Street, 01845 Director � =r NORTH ANDOVER (508) 682-6483 BUILDING , .� CONSERVATION DIVISION OF PLANNING PLANNING & COMMUNITY DEVELOPMENT i March 5, 1992 Joseph Stella 104 Meadow Lane North Andover, MA Re: 16-18 Lincoln Street, North Andover Dear Mr. Stella: This is to notify you that you are in violation of the State Plumbing and Gas Code with regard to new gas-fired hot water heater installed on 12/12/91 at 16-18 Lincoln St. without a Permit. If we do not hear from you immediately, it may be necessary to file a criminal complaint against you for this violation. ry truly yours, James L. Diozzi,� Plumbing & Gas Inspector JLD:gb c/K. Nelson, Dir. (J 1 I SENDER: • Complete items 1 and/or 2 for additional services. I also wish to receive the • Complete items 3,and 4a&b. following services (for an extra • Print your name and address on the reverse of this form so that we can fee): return this card to you. • Attach this form to the front of the mailpiece,or on the back if space 1. ❑ Addressee's Address does not permit. • Write"Return Recent Requested"on the mailpiece below the article number. 2. ❑ Restricted Delivery • The Return Receipt Fee will provide you the signature of the person delivers to and the date of delivery. Consult postmaster for fee. 3. Article Addressed to: 4a. Article Number 4b. Service Type 1 ❑ Registered ❑ Insured Certified ❑ COD 1 ❑ Express Mail ❑ Return Receipt for Merchandise 7. Date of Del' ery 5. Si n r (Add res 1 8. Addres ee's Address(Only if requested zz and fee is paid) 6. gighature (Ag)e PS Form 3 1 ve ber 1990 *U.S.GPO:1991-287.066 DOMESTIC RETURN RECEIPT UNITED STATES POSTAL SERWE •� V JC� it '. S f' Official Business C US MAIL PENALTY FOR PRIVATE USE, $300 1 Print your name, address and ZIP Code here r P 290 099 213 RECEIPT FOR CERTIFIED MAIL NO INSURANCE COVERAGE PROVIDED NOT FOR INTERNATIONAL MAIL (See Reverse) N ' N v N m Street and IN h aP. tate a IPC de AAa N Postage S �J � G Certified'fee Special Delivery Fee i Restricted Delivery Fee Return Receipt showing to whom and Date Delivered �— N m Return Receipt showing to whom, Date,and Address of Delivery d j TOTAL Poste a6d Fees, S 77 0 Postmark or Dat@. Lam; E LL fp / STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES.(see front) 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier. (no extra charge) 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the at isle by means of the gummed ends if space per- mits.Otherwise,affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee,or'to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return + receipt is requested,check the applicable blocks in item 1 of Form 3811. i 6. Save this receipt and present it if you make inquiry. *U.S.G.P.O.1989-234-555 KAREN H.P.NELSONr Directs Town of 120 Main Street, 01845 BUILDING `• NORTH ANDOVER (508) 682-6483 CONSERVATION �BCHUDIVISION OF PLANNING PLANNING & COMMUNITY DEVELOPMENT March 5, 1992 Joseph & Rita Stella 104 Meadow Lane North Andover, MA Re: 16-18 Lincoln Street Dear Mr. & Mrs. Stella: All indications are that you have proceeded to construct an apartment on the third floor of subject dwelling, permission for which was denied by the Board of Appeals in its decision dated August 16, 1988, Petition #7-89. I hereby request that you make an appointment to meet with me so that I may inspect the premises in question in order to determine the extent of the violation. Your immediate attention to this matter is imperative. Yours truly, 1 � D. Robert Nicetta, Building Inspector DRN: b g c/K. Nelson, Dir. � J i i i I { s Date...... ..... q N- 1143 HORTM °ft"` °1"� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SS^CMUSE� This certifies that ...... .. ......................... O � has permission to perform ..... ........................ wiring in the ilding f....... . .......... ..................................... at......�. .1. ... ... ... . .. .. .. .. ............. .North Andover,Mass. Fee... ................. Lic.N 2 L I@Ai! WHITE: Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File ✓ U �� ��j 'G � y,�S ��o: �� q, bzi tMK: HUARDOF FIRE PREVENTION REGULATIONS VIC Commonwealth of Massachusetts °"'"°~°a'r D"rtmenf of Public Safety ►...te�. 11OARt)OF FIRE PREVENTION REGULATIUIRONS S21 CMR 1200 e<e tat« /90 tts..s ai�aU APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Ali aeu4 to be pttforuned In aceerdanee with tht Mawchwtes El"kal Cedt.$21 CMR 12:00 (PLEASE FRIt(x Ill IHR O �TTPEIFOSI0 ` City or town of To the Inlpeeto t Wirest The undersigned applies for a permit to petfors the el meal cork described betew. lecatiOn (Street 6 Huflber) 1 * 0%mer or Tenant A� r n�+•r•s Address Is this per"tt In Conjunction wi h a bulldin perut6 Yet ❑ Ne ❑Cheek Appropriate tax) purpose of Building 7 e / � utility Authoiilation N0 Existing Service Amps / i✓Volts Overhead ErUndgrd❑ No.•e! Meters New Service Arps /. Volts Overhead ltd. ' %-dtrd❑ No. o! Meters Ilwber of Feeders and Aepacity Location and Nature of Proposed Electrical Work 8 t• , �J=� .load- No. of Lightin Outlets No. of Not Tubsota No. of Transformers KvA f+n. of Lighting Ftxtures Swimting PoolAbove n- grnd.❑ rnd. ❑ Ceneraters KVA No. of Receptacle thitie:s No. of 011 turners No. of Emergency Lighting BatteryUnits No. of Switch outlets No. of Cas turners FIRE AtAmts No. of Zonis No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals Ho. of Peau Total Total No. at Sounding Devices No. of Dishwashers Space/Area Heating kW "a. ofthIf Sounding Device*Contained No. of Dryers Heating Devices Rif Local❑Hineelpst Other No. of Water Heaters KW 140, o Ballasts LewWirVoltage nt No. Hydro Hassage Iubs No. eE Motors Total RP ontER: INSURANCE COVERAffi Pursuant to the requirements of Massachusetts Ceneral Laws I have a current Llabl=l'ity Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES(j�NO[] I have submitted valid proof of some to this office. YES® 0 If you have checked YES, please indicate the type of coverage by Che Ing the appropriate box. INSURANCE. Ej OTNER[] (Please Specify) qf /Jarat`on at Estimated value of Electrical Work S '7--� ��' n Work to Stam p'I Inspection Date Requestedi Rough Final Signed tinder t e enaltles E perjury, t tip" NllitE F. e_ - I C� LIC. 110j)-LI � Ltcensee4 �� /� r t 4 Signature NO. sus. Iel. Nod. ' Alt. Tet. o A r OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insure ' e coverage or to au - atantial equivalent as required by Massachusetts Ceneralws� an tat my signature on this permit application waives this requirement. Owner Agent (Please cheek one) Telephone No. PERMIT FEE S Signature of Owner or Agent i REGULATORY AUT110R11•Y I' 522 CNIR 12.00: M.G.L. C. 22, S. 14; C. 143. s. 3L; c. 148. S. 10. SII 3/10/90 (Effcclive 3/15/90) 114.5 EMERGENCY C01IfIC099-OF INSURANCE 1 PRODUCER t THIS CERTIFICATE IS ISM AS A MATTER OF INFORMATION ONLY AND CONFERS I I Samuel J Durso Ins. Agcy, Inc. I NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT We, I I I EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I 1 198 Massachusetts Avenue {--- ------- ----- - -1 North Andover, MA I 1 1 01845-4190 I COMPANIES AFFORDING COVERAGE 1 I I PHMOS-688-5175 I I I COMPANY LETTER A- Travelers Insurance Company 1- -I I Canney E 1 ect r i c f COMPANY LETTER B I I Thomas P. Canny I -- -- ---I I P.O. Box 118 1 COMPANY LETTER C I I Methuen, MA 1--- -------- -------- 1 1 01844 1 COMM LETTER D I 1 1— ____________ --------1 f I COMPANY LETTER E _ I I> COVERAGES t--T--=- I THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IBM TO THE INSURED NAMED ADM FOR THE POLICYM� I I PERIOD INDICATED. NOTWITHSTANDING ANY RE(lUIREMENT, TERN OR CONDITION OF ANY CONTRACT OR OTHER DOi1Ma1T WITH RESPECT TO 1 I WHICH THIS CERTIFICATE MY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO 1 I ALL TERNS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY WAVE BEEN REDUCED BY PAID CLAIMS. I I COI TYPE OF INSURANCE I POLICY NUMBER I POLICY EFF I POLICY EXP I ALL LIMITS IN THOUSANDS I ILTRI 1 I DATE I DATE 1 I I I GENE RAL LIABILITY I i i { FERAL AGGREGATE 1500 I 1 1 1 I ! ! —1--1 I AI 00 COMMERCIAL CEN LIABILITY 1650690J6223COF9 03/22/90 05/22/91 1 PRODS-COMP/OPS AM. 1500 1 J r t r t r 1 CI oto-- I OCC i j -'� PERS. & ADVS. INJURY1500 I I\\ I i I I t ---------------f -I I I [ ] OWNER'S 6 CONTRACTORS I 1 I I EACH OCCURRENCE 1500 1 ! I PROTECTIVE { I { {---- ----1 --1 I I 1 { I I FIRE DAMAGE I t ! I I I i I I (ANY ONE FIRE) 150 1 I I [ ] 1 I I 1 MEDICAL EXPENSE I ! I 1 I I I I (ANY ONE PERSON) 11 ! I AUTOMOBILE L I AB I i I I CSL I i I 11 ANY AUTO 1 I I I BODILY INJURY f I I f [ ] ALL OBD AUTOS I 1 1 I (PER PERSON) I ! I i [ ] SCHEDULED AUTOS I I I I -- 1-----------! I I [ ] HIRED AUTOS I I 1 I BODILY INJURY I I 1 I [ ] NON-OWNED AUTOS 1 1 I I (PER ACCIDENT) I I I f I ] GARAGE LIABILITY I I I 1 1- —1 I t [ ] 1 I t I PROPERTY I I 1 t E X CESS LIABILITY I -� i I I I EACH OCC I-AGGREGATE ! I 1 1 UMBRELLA FORK I I I I I 1 I I I I ] OTHER THAN UMBRELLA FORM I E I 1 I I I 1-1- I —1-I I I I I I STATUTORY E 1 1 WORKERS' COMP I ! 1 ! E(Ctl AMC 1 f 1 AND 1 ! 1 I DISEASE-POLICY LIMIT I 1 I EMPLOYERS' LIAR I I I I DISEASE-EACH EMPLOYEEI I I OTHER 11 I I 1 I 1 I I I I I f 1 I— I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS 1 I Electrician. 1 � 1 i I 1 i I 1 1) CERTIFICATE HOLDERj I CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED FOLICIES BE CANCELLED BEFORE THE EX- I 1 = PIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MIL 10 1 I Town of North Andover = DAYS WRITTEN NOTICE Tb THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT I I Town Hall = FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF I I North Andover, MA = ANY KIND UPON THE COMPANY) ITS AGENTS OR REPRESENTATIVES. 1 1 01845 =----------------------_ -------1 f = AUTHORIZED REPRESENTATI IACORD == 5 �@�� k TOWN OF NORTH ANDOVER r10RTM APPLICATION FOR PLAN EXAMINATION Oft�,,o ,anti •e ° Permit NO: Date Received ,�b/ Lo4 � ' Date Issued: �Y SsCH _ (( IMPORTANT: Applicant must complete all items on this page LOCATION /(o - a L(/I Coll I Print PROPERTY OWNER JG Print MAP NO.: q 0 PARCEL: 39 ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building ne family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: Repair, replacement ❑ Assessory Bldg ❑ Commercial Demolition El Moving(relocation) ❑Other ❑ Others: Foundation only DESCRIPTION OF WORK TO BE PREFORMED S � i an re r Identification Please Type or Print Clearly) OWNER: Name: ��o,�p� �, S�,( �� Phone: c)-7 � Address: _ _ hY13allf,, fl CONTRACTOR Name: "-Tod ` ,l d (kc- Phone: –/1- Address:_ C2- b Sy" tbol\ S� (tek f 1 cr4G, '6 Y13 6 JfC- Supervisor's Construction License: Exp. Date: Home Improvement License: t{ %9 Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. i I FEE SCHEDULE:BULDING PERMIT.-5/ .0 PER$/0/10.00 OF THE TOTAL EST/.MATED C ST BASED ON 5125.00 PER S.F. Total Project Cost :$ I' FEE:$ Check No.:-1Receipt No.: Page Iof4 i TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimming Pools C Public Sewer Well J Tobacco Sales F-7-J Food Packaging/Sales E. Permanent Dumpster on Site ❑ Private(septic tank,etc. ❑ Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor 5 C Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date _ COMMENTS Zoning Board of Appeals: Variance. Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer connection/Signature& Date Driveway Permit Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA— For department use i I Pa;c 3 of-4 Doc:INSPECTIONAL SERVICES DEPARTMENT:1313FORM05 Created 1MC 1:1,1201)6 I f i. I Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ BuildingPermit t Application ❑ Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc.INSPECTIONAL SERVICES DEPARTNIEN'r:BPFORb105 Y II Page 4 of 4 1 S Location No. '' Date �'"� -ll NORTH TOWN OF NORTH ANDOVER 3?0�,,`•o,",MOL N 9 Certificate of Occupancy $ ♦ O� <w�i�w<. 4 � l ��s •t<� Building/Frame Permit Fee $ 4-14�— Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �+ { 19794 Building Inspector NORTH ® Of . � _ RAndover 104 L A dover, Mass., COCMICMEWICK,y1 7d ADRATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... .�V...........................\........,.................................................................................. Foundation has permission to erect.......................... ....... buildings on`......��.�. ........... M.�...�K......a T�........ Rough to be occupied as Srjr. eli�ii .................. ........... ........................ ..�...�.............................................. Chimneyprovided that the person accepis permit shall 16 ry respect conform a 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 Final PERMIT EXPIRES IN 6 MONTHS ELECT_ RICAL INSPECTOR UNLESS CONSTRUCTIO S Rough ........ ........ Service .. . . . .. .. ...... ....... BUI G 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. Bumer Street No. SEE REVERSE SIDE Smoke Det. ✓gyre ioanvinaraufecaGCh a`✓7/Caeoacfiuoelta Board or Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 104569 Board of Building Regulations and Standards Expiration: 7/14/2008 One Ashburton Place Rm 1301 Type: Private Corporation Boston,Ma.0210$ DAVID CASTRICONE ROOFING,SIDING& David Castricone 200 SUTTON ST SUITE 226Jz NORTH ANDOVER, MA 01845 Deputy Administrator Not valid without signature I i I I i I INTt •A�'+I RD, CERTIFICATE OF LIABILITY INS URANCE PRODUCC:R DATE(MNUDDj") Internet Insurance Agency THIS CERTIFICATE IS ISSUED AS A MATER�lNFORMAT 6/2006 522 Chickering Road HOLDERTHIS IRTIFICACONFIERS �B DOES N07 ENp IF pRTE North AMdoVer, MA 01845 ALTER THE COVERAGE aFFORDQD BY TNL'POLICIES Be IHBURrp INSURERS AFFORDINGCOVERAGE DAVID CASTRICONE NSURERA, NORFOLK 8 DEDHAM NAIC�I ROOFING AND SIDING INC, U18uPeR B; NORPdLK$DEDFIgM 200 SUTTON STREET,STE,226 INSURER C; AIM NORTH ANDOVER, MA 01845 wauRERo; COVERAGES INEVRER=; THE POLICIES OF INSURANO@ L;BTEA 9ELOW HAVc SEEN IBB ANY R@OUIRE.MENT.TERIA OR ''I ,E INSURGD rVANEJ ABOVE FOR THS POLICY P F! QTAIA,THE INSURANCE AFFC DS013Y E PO C ESRAC',aR OTHER DOCUM L DES„R18ED HEREO I E(NT WfTH RESPECT TO WHICH T ;ER INJICATEn.NpTW TH87ANDINt3 POUCIES.AGGREGATE LIMITS SHOiNN MAV NAV$BEEN Rc $SUBJECT TO ALL'rIE T'R HIS CERTIFICATE MAYBE ISSUED OR MAY DUCBC 3Y PAID CLAIMg a M9,EXGLUSIOfJS AND CONDITIONS OF SUCH L NORD TYPEOFiNSUIW(ICE A GRNCRgL LIAERIrY POLICY NUM6pR X ✓ COMMERCIALGENERALLIABILrTY tiD•P•009$67 8192/2008 8/12/2007 uMrTs EAC 1 OCCURREroOE 6 7,000;0040 CLAIMS MADE OOCUR CA I P "�n � SD•000.00 f I 20 E%p(Anfm-Person) g 5,000.00 PERSONAL A ADV INJURY t ",000,000.00 GENT AGGREGATE LIPAR AP°LIES PER; O:NERAL AGGREGATE 6 I,ppp p00,00 POLICY PROJECT LOO PRCDUC-t.CDMpl4Pg6a^ b B AUTOMOBILE OABILITY 1.000,000,00 44505�i00001 ANY AU+'C OBi01/2006 ga/0112007 i RM ALL OWNED AUTOS ))E2.IVJJ INGLE LIMIT s W, SCHEDULED AUTOS HIRGDAUTOC � DIL��IN��URy S a50,000AD NON-OWNED AUT03 Y'�N�JBURY 6 WICK= PROPER�'ryyDAMAGE $100,000,00 GARAGE•LIA911,ITY (P-2r aCdden:) ANY AUTO AUTO ONLY.EA ACCIDENT 8 AVER THAN EA AOC 6 EX"SwUNI8RELLA LIMILITY A O O LY: AGO OCCUA CLAIMS MADE EACH OCCURRENCE f AGEREGATE E DEDUCTIBLE 8 RETENTroN 6 + 8 C �OT FW L1A6IOOMPCNL9i"N•nONAND VWC 6006480012004 ANYPRR��ppRIETOR/PARTNBRIWOUTIVE 09/23/2008 09/23/2007 T RY ITS OyFFICER1MSMAER&NGLUOED?he Under EL EACH ACCIDENT s 100,000.00 PGr IAL PPROVIBION8 bekyi llO65ASE•EAEM24YEE g 500000.00 OTHER I.L.bl87A8E•POLICY LIM, i '00,000.00 r CERTIFICATE HOLD ER CANCELLATION SHOULD ANY OP THE ABOVE oESC REQ Pou01E9 BE pip I cn SEFORp THE DATE THEREOF,THE 188MG INSURER WILL ENDEAVORTO MUL 030 n,�Ys r�RmEN i;XPIhEN NOTICE TO THE CERTIMCAT9 HoLoCA NAMOD TC THE LEFT,Bur FAILURC TO Dp 80 eNgll WPOBE NO OONGATION OR LUUBI,(}y OFANv IUND UPON REPRESGNTATIY�, TH!INSURER,ITS AQ%NTS OR A NORIZEDAVR88EW7ATM ACORD 25(Z0011OE) QA RD CORPORATION 1988 II i i I Town of North Andover tkORTH : �o -zo ,6�� i Building Department o L _ 27 Charles Street North Andover,Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 °� OATe o I',? A'b ITACHUS i DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit# the debris resultingfrom the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150ap The debris will be disposed of in/at: IN Facility location Signature of Applicant 13 0 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Department of Industrial Accidents r 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 Legibly Name (Business/Organization/Individual):a)oy i d Cao- 6 con o_ Rp©Aj hG J Address: o7 c)O &4t r S-4-ree+ - Sicx ZZ(.. City/State/Zip: N p. A0&df MA Phone#: q77 f G � 3 3 YZ o Are you an employer? Check the appropriate box: Type of project(required): 1.)6 I am a employer with__% — 4. ❑ I am a general contractor and I employee's(full and/or part-time).* have hired the sub-contractors 6. EJ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical r airs or additions required.] officers have exercised their ep 3.❑ I 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.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.[:] Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 jab site information. Insurance Company Name: •..L- _' ' Policy#or Self-ins. Lic. #: V VV C OO 1 T Expiration Date: 9%a�,3.,Q S Job Site Address: a Shui City/State/Zip: /l.! / ref 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 tine up to$1,500.00 and/or one-year"imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern der the ins and penalties of perjury that the informationprovided above i true and correct Si ature: C D Q r7 [ ate: f Phone#: l Official use only. Do not write in this.�`� y s area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): f 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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. mP 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 of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia J � ve,.,lt_.r G r DAVID CASTRICONE 1Y,, ,A ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET,SUITE 226,NO,ANDOVER,MA 01845 lJ 7 HILLSIDE ROAD,BOXFORD,MA 01921 In North.Andover 978-683-3420 In Bo4ord 978-887-6147 OCT 13 1,200 In Haverhill 978-374-7314 b I/we the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all neeclaty--- materials,labor and worlonanship,to install,construct and place the improvements according to the following-specifications,terms and conditions,on premises below described; Owner's Name......1j..G..1.e fr. ...,a... .t~�1. ...................................................Telpph I . 0-10...:". .......... Job Addre . ................State........ a ................... y...../ j ... / ......... Specification: l trip ezlsting shingles............}pP'1Yttew drip edge to all edges. .......... .................................................................................... i.... ... ......................... ....... ... .. ........... . ......... ................. . . .............. ✓Apply feet ice an..d..water...:..s.Meld.membrane. .. ...to...bottom.. .. .. .. . ed es of house.. ..... . 3 fee.t. .. ice and. . . water shield.......membrane.. . . ............. In valleys and bottom edges of an unheated areas of house. _ ....................................... .....Y .. +L� yYr s=........ --Apply felt paper underlaymi t. -Install ridge vent to.... t.. ............................................................................................. rt .,ter' ........... �. °1 ..... ' ":..�:............ ........................... veroof using 4 r.. shingles with a .......... .................................. ...................................... Year..... ty. �-Countertlash chimney. �w vent pipe flashing. ✓Legal disposal of all debris, � 1 Areas)to be worked on:...................... ...................................................................................... .W..�.rt...l:C/... FF.......... .:.�I.........j7(.1.1....I'.t7. e. .. .�,ti.[Lrest.5.... ..1� ................................. .,, ....................................... ................. ........................................................... ...................... r `..:. ."... .................................................................... .................... `.. ,. ....: ,:.:S..t ;,u� W. ............ ..d� ....i.........G.o. 1.....Ja.t ... ..k;. ..j e ....... ........................ One Year Workmanship Warr y(N9J,,Transferable) Manufacturer's Warrant as c fl b 'amu eturer i •" ' Y� i Materials and Labor to coc, S. . . ., t.....,f,. Pa atbia......... _..........on.....�..z.�!..... .- . Payable..........:::................on................. ..../� al cc payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumbling plaster,exposed nails)or conditions resulting from application of materials specified above (i.e.objects coming loose from wails,crumbling plaster,exposed nails,dust in attic or other living spaces,water stains when roofing shingles have not had adequate time to cure). Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation as requested by contractor.Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaid,immediately due turd ppyebk. It Is agreed that,if permitted by law,contractor shall be paid by the owners)all reasonable costs,attorney fees and expenses,in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor,and also that the obligations hereof shall bind and apply to their heirs,successors or estates. The undersigned warrant(s)that he is(they are)the owners(s)of the above mentioned premises and that legal title thereto stands of record in his(their)names(s). There are no representations,guaranties or warranties,except such as may be herein incorporated,if any,nor any agreements collateral hereto,nor is the contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration One Ashburton Place Room 1301,Boston,MA 02108 Tel:617.727-8598 i Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secures his own construction-related permit or deals with unregistered contractors shall be excluded from access to the Guarantee Fund. Approximatestarting date of work...................................................................... Completion date.............................................................. Receiptof a-copy of.this_contract is he 4>by.agknowledged,'.raid.1t,is Airthoracknolvledged_by,the tundorsi�.ed-digt.the.forsgpin •- provisions have been read and the contents thereof understood and that no representation oeagreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner has three business days to cancel this contract and incur no penalty. IN WITNESS WHEREOF,the parties have hereunto signed thelr names this day of.............. ,20.............. Accepted: ............ .... -------- Signed . ....... . ... .. ... .. .. mer Signe .. ..................................... ...................................Owner Per....................................................................... Representative