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Miscellaneous - 173 COACHMANS LANE 4/30/2018 (3)
This certifies that ..% ..... ............................ . has permission for gas installation ............ in the buildings of .. ....... ............................ at North Andover, Miss. ,, . Feeg�.ggo... Lie. No......... . Check # 8650 ........ ...f...... GASINSPECTOR I (J TYPE OR PRINT CLEARLY ,MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: NORTH ANDOVER MA. DATE: 03/04/2013 PERMIT # JOBSITE ADDRESS: 173 COACHMANS LN OWNER'S NAME: PEGGY ISSENBERG OWNER ADDRESS: TEL: 978-857-1866 FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL , , / NEW: Lam' RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES El NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted (or entered) regarding this permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME;&t±-!� /3aYSex/ LICENSE # �3 3 SIGNATURE COMPANY NAME: OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP: 01844 FAX: 978.738-0118 1�\� TEL: 800-368.9956 CELL: EMAIL: INFO(@OSTERMANGAS.COM �\ \ MASTER ❑ JOURNEYMAN ❑ LP INSTALLER ORPORATION ❑# PARTNERSHIP ❑# LLC E] #45.326.3311 d I �: , t � i� :.� i� i� i� �' r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Ulf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors F1 Remodeling 2. El am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have 8. ❑ Demolition workingfor me in an capacity. y p ty workers' comp. insurance. 5. ❑ We are a corporation and its 9 El Building addition [No workers' comp. insurance required.] officers have exercised their 10. ❑ Electrical repairs or additions 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' 13.n'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 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. A Insurance Company Name:. Policy # or Self -ins. Lic. Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certtfy under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: e 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-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 retained 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 of Investigations 6.00 Washington Street Boston, MA 02111 Tel, # 617-727-4900 at 406 or 1-8777MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,gov1dia y � Invoice 1A yantage-fireplacejnc. 261 Primrose Street Haverhill, MA 01830 978-372-8115 Phone 978-556-9304 Fax advantagefireplace@comcast.net www.advantagefireplace.com Date Invoice # 1/18/2013 18411 Bill To Ray Parkhurst Remodeling 44 Bateman Street Haverhill, MA 01830 P.O. No. Terms C.O.D. Item Quantity Description Rate Amount Misc 1 Up 4' and roof flashing in stalled(additional charge over the direct 145.00 145.00 vent price already billed) Glass choice is not chosen or ordered yet, but is billed on first invoice. Tax included 0.00 0.00 Late Payments: A FINANCE CHARGE is computed by a "Periodic Rate" of 2% per month on all PAST DUE accounts. You shall be liable for all collection costs and legal fees. Job Address Total $145.00 173 Coachman's Lane North Andover, MA J LENNOX v - a HEARTHPRODUCTSESUPE Y L 261 Primrose Street Haverhill, MA 01830 978-372-8115 Phone 978-556-9304 Fax t tA-dyantage 0=1ace, Inc Invoice Tina Maglio 261 Primrose Street Customer Service Haverhill, MA 01832 Date Invoice # LENN©X Tel: 978.372.8115 1/14/2013 18367 "r"""1°NOOUC7Y Fax: 978.556.9304 ESUMIOR- E-mail: advantagefireplace@comcast.net advantagefireplace@comcast.net www.advantagefireplace.com Bill To Ray Parkhurst Remodeling 44 Bateman Street Haverhill. MA 01830 P.O. No. Terms C.O.D. Item Quantity Description RHAP421N 1 H8612 42" Rhapsody direct vent gas fireplace, top vent, louverless, with infini-flame burner, total comfort remote control system with battery back up, switchable standing pilot mode and ceramic glass, with designer black porcelain floor and nake black porcelain panel kit, up 6", direct vented, installed. (Homeowner quoted list pricing fireplace only no venting not installed.$4649.00)No floor glass choice has been chosen but is included in price. Tax included Late Payments: A FINANCE CHARGE is computed by a "Periodic Rate" of 2% per month on all PAST DUE accounts. You shall be liable for all collection costs and legal fees. Job Address 173 Coachmans Lane No. Andover, MA LENNIN a ,�, (A (C G GAJ- 111ARTH PRODUCTS Rate I Amount Total - J'f � 1„1 SUPERIOR. 7W"59-16 Datel:�-..o . . . ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ........................ 0 .............. A ....... ........... lrv'" .. .... has permission to ................. wiring in the building of . ..... .. ........ at X.7 .... ....... ............. . North Andover, Mass. ......... ....... ud .......... Fee:f .............. Lic. No/7`/*/`.-. ..................... ... ELECTRICAL INSPECrO Check # • Commonwealth of Massachusetts Official UseOnly Department of Fire Services Permit N BOARD OF FIRE PREVENTION REGULATIONS pancy and Fee Checked_ 19 ev. 11/99] leave blank APPLICATION FOR PERMIT TO PER RM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: /N/0r�h %�4 Ver To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) C oacb men L0j_1 C- Owner or Tenant M r -T55 en beirG Telephone No. Owner's Address ="-:�_ V\n,p a< --"a, 00 V -C Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 2e-20 eab Utility Authorization No. Existing Servicec;WD Amps ab / cDyjDVolts Overhead �n Undgrd ❑ No. of Meters New Service �.�� Amps / Volts Overhead,l,J Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Picker) rem e' new. wO�%c Completion of the followine table may be waived by the Inspector of N%—p, No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans o. o otal Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑IN rnd. grnd. o. o f Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. oDetection an Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pumum Totals: p er ons " ' "'""""'.'"......""'" o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW ecuritySystems: No. of Devices or Equivalent No. of Water KW Heaters 0.0 No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, oras required by the Inspector oj' JVir es INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑. BOND ❑ OTHER ❑ (Specify:) One ( deo Cpin 0(0 G6 - (Expiration Date) Estimated Value of Electrical Work: -A26 oc Z (When required by municipal policy.) Work to Start: -� —Q5 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: C -CL -1 ! a -V 2C4—rI`C LIC. NO.: Licensee: 4 ) I 2 n a- C Cd I CLV-14 Signature LIC. NO.: j t2113 A (If applicable, enter "exempt" to the lie nse number line.) Bus. Tel. No.: 7 S I'£S(�- `/t✓ �(�� Address: �I C `/ ID /`OQ r k3 line.), Bus. {I 612-3 U Alt. Tel. 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 PERMIT FEE: S `j °o Signature Telephone No. �A Commonwealth of Massachusetts official use only Department of Fire Services Permit No. �S9�(P BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked`r [Rev. 11/99] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALLINFORMATION) Date: City or Town of: CSr��i1 %/Q ((P To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) /9a C 000J1Meln Lain P Owner or Tenant M r Telephone No. Owner's Address _,:�Y rM,P Q d �� V 'e ' `� t x ' T�',/7 Is this permit in conjunction with a building permit? Yes Purpose of Building 6�6c ter? 6 GSC No (Check Appropriate Box) Utility Authorization No. Existing ServiceoZ00 Amps Lao / ayDVolts Overhead 29 Undgrd ❑ New Service Amps / Volts Overhead Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r-14-( Com letion o the !! b! No. of Meters No, of Meters Arraen aaaumonai detail iJ desired, or as required by the Inspector o/ kkr es INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [3 BOND ❑ OTHER ❑ (Specify:) Qne Be(, _p(n 04 66- lEstimated Value of Electrical Work: 02(00O (When required by municipal policy.) (Expiration Date Work to Start: — J —Q Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the Information on this application Is true and complete. FIRM NAME: Gc ( CL(n 61 e c 4--f 1, c LIC. NO.: Licensee: 14) f n 13 . C -C4 -1I CLU1 . Signature LIC. NO.: (/f applicable, enter "exempt" in the lone number fin .) Bus. Tel. No.: 1$I-K� Address: _ �1 C Y p %` pG U d� i'c� MV-� (x/73 U Alt. Tel. 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 PERMIT FEE: $ �, �0 Signature Telephone No. 0 owin to e may be waived by the Inspector o/ hi'ires No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans 0.0Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ n- a o. o merge ncy ig ing rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMSNo. of Zoges No. of Switches No. of Gas Burners No - of etection an Initiatin Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat Pump Totals: um er "' """""""" ons """"""""""'""""''"""'""'' o. o e = ontaine Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El Connectunicipa n El io No. of Dryers Heating Appliances KW SecuritySystems: No. o ater o. o No. of Devices or Equivalent Heaters KW aor— Signs BaIlasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecom munic—a—fl—o n—s firing: No. of Devices or Equivalent OTHER: Arraen aaaumonai detail iJ desired, or as required by the Inspector o/ kkr es INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [3 BOND ❑ OTHER ❑ (Specify:) Qne Be(, _p(n 04 66- lEstimated Value of Electrical Work: 02(00O (When required by municipal policy.) (Expiration Date Work to Start: — J —Q Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the Information on this application Is true and complete. FIRM NAME: Gc ( CL(n 61 e c 4--f 1, c LIC. NO.: Licensee: 14) f n 13 . C -C4 -1I CLU1 . Signature LIC. NO.: (/f applicable, enter "exempt" in the lone number fin .) Bus. Tel. No.: 1$I-K� Address: _ �1 C Y p %` pG U d� i'c� MV-� (x/73 U Alt. Tel. 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 PERMIT FEE: $ �, �0 Signature Telephone No. (Z 0 cly 0 k 7, - &� 0 v S �� Date�'.o?�? -�5' AV d� of, ORT " - TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING ,• 2 , This certifies that .............. ... has permission to perform �!�^-�-''.... .......... . dumbing in the buildings of .??� ............. -�--Nh Andover, Mass. Fee . � ..... Lie. No. f.� f l '. �: % -Gt '' ............ PLUMBI_NG"NSPECTOR Check * 133 F 6547 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS 7 1 y� ,f)IC4 �ci���U� Date Building Location / � �i�Cl�/f���5 Owners Name Permit #--*P—� Amount ') 6-v Type of Occupancy New 0 Renovation/0 Replacement 0 Plans Submitted Yes No J9 FIXTURES (Print or type)/ // C ec ne: ertificate Installing Company Name l�/ `� ' AIZA, !�/ C�f ��C' Corp. Address P-0 - dal ' Partner. 'eaL l47/ Business Telephone - Frm/Co. Name of Licensed Plumber: Insurance Coverage: Indica type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond El Insurance Waiver: I, the u dersigned, have been made aware that the licensee of this application does not have any one of the above y three insurance Signature Owner D Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that.all plumbing work and installations performed under Pe(�ssuedr,! _ t�p n will be in compliance with all pertinent provisions of the Massachusetts State )?j ' g�op an Vr o e Laws. Type of Plumbil g License is n e iNumDer Master D (OFFICE USE ONLY Journeyman 1-3 U/ Date....: �...A.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation -' ` ........... 400 the buildings of .................... at I�Dnii -A-0no dover, Mass. Fee.> % .. Lic. No. �?/ . \, ��' � ............ GAS INSP C OR Check # �� -'/ 5189 �4A MASSACHUSETTS UNIFORM APPLICATONFORPERNIlTTODO GAS F MNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date 7lZ-& Building Locations // �4���/`Y Z/J Permit # 9 Amount $ 3�cS7� ,DIS c�s56.t, � Owner's Name New ❑ Renovation Replacement ❑ Plans Submitted ❑ (Print or type)ec one: Certificate Installing Company Name - �oL1 /%� Corp. 714 0 C Address/ �� `J �� ❑ Partner. usmess Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Chect o : I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checkedyes, ple se indicate the type coverage by checking the appropriate b [3Liability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: r1am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information i nave sucrmaeu fur cuLcicu) 1,I auvvc aFY,icauvu aic uuc a,iu a�uiaLc L., Luc best of my knowledge and that all plumbing work and installations performed under Permit Issued for his application will be in compliance with all pertinent provisions of the Massachusetts Stat�Wode and CIMPZ142 of Gy!rral Laws. 10 11 Y itle IAPPROVED (OFFICE USE ONLY) Signature"-iffLicensed Plumber Or Gas Fitter Plumber Gas Fitter T77cense Number Master Journeyman �B A SEM ENT (Print or type)ec one: Certificate Installing Company Name - �oL1 /%� Corp. 714 0 C Address/ �� `J �� ❑ Partner. usmess Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Chect o : I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checkedyes, ple se indicate the type coverage by checking the appropriate b [3Liability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: r1am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information i nave sucrmaeu fur cuLcicu) 1,I auvvc aFY,icauvu aic uuc a,iu a�uiaLc L., Luc best of my knowledge and that all plumbing work and installations performed under Permit Issued for his application will be in compliance with all pertinent provisions of the Massachusetts Stat�Wode and CIMPZ142 of Gy!rral Laws. 10 11 Y itle IAPPROVED (OFFICE USE ONLY) Signature"-iffLicensed Plumber Or Gas Fitter Plumber Gas Fitter T77cense Number Master Journeyman ` f Location No. Zf7 Date TOWN OF NORTH ANDOVER f � s A T � # # . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # �� G i 8351 �/"—Building Inspe6qc .4 �.e TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPL[CAl WTOCO>+iliPAUG?RBP SBIWWA Olt DffiNOIDBAONBORIWOFAMQ,XDVt'B1.iDRi BuRDINO PERMIT NUMBER 2 17 DATE 1SSIIED: SiODTATURE: Dai SECTION 1- SIT= INFOR19unco 1.1 popeety Mdrees: 1.1 Ai aeere 2Aq asd Pared Nsrtdrer 01-3 C��.,.��� ✓. G i�po d map taeebe Psrod Numbs 1.3 Zang Wamatias: 1.4 nVisty Dimemiaa Zesis Dilritthopaw use 1A Am IA BUDDING SETBACi{S 00 Front Yard Side Yard Rear Yazd Provide Re=iW PfWMAd RcohW Pravi" 1.7 wow Esp*MOLCAI St113 PbeWTiseldomdec 1.S' 6twayoDbpnlSypme Z0w O"h Flnd Z= 0 MaWpd 0 a Sho Mpad Syms 0 PASO 0 p"s a SECPION 2 - PROPERTY OWNEBSDIPIAUTHORI7,B1D AGENT 2.1 Owner of Reeord .1 u1CAL d'7 ? I-fJ � �� Mdmsslor Service - �-- 769 g T 2.2 Owner ofRecadu Name Print Addressfor Service: SkuhnT SECTION 3 - CONSTRUCTION SERVICES 3.1 Wood Construction Supervisor. Not Appfic" 0 Dv J6 -S U LWOW Ceoawctial StPIrvisor Sl kv0005locl Lima Number Addressi2_-7G Tekpbon/`e,,,,�y Home Improvemast Cel NO Ap*" 0 31cavo;' ? �� c fo Narober 3-7-`7 ®'�U6Z. t. . l oc) Evirmion Dm s' Tdabaree aennnx e _ atnoifV 24 MIXIM ATIM [Wil -L C 142 i 2WIQ wades ctioa Iaauranoe.�dnit m� be oomplead aad �bmdred � Ibis �ppb�atioo. FaOnra td provide mia.f5d.vit wI1 remit io the daaid die;» of tk . Shmed offid * AUKW Yes ......13 Na....... SKMON3 D6c dPropwW Werk creki New Construction - ❑ Existing Building 0 Repau(s) ❑ Ahcmtions(s) Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Desuiption of Proposed Wads 4—.!D New C4/3 rs Ti 1 '� SECTION 6 - ESTIMATED CONSTRUCTION COSTS [tern EdbrAtW Cast (Dollar) to be ded bY VPIICW , g Pamit Fa 1. Building 27,500 (a)mukwicr 2 Electrical Y!500 (b) Estimsted Total Coat of Conshuction 3 Pit®' 2Sts o Building Permit fee (•) 2.(b) 4 MacbROW AC - D 5 Fire Pronation 6 Total 1+2+3+4+5 Sze Chock Number SECTION 7a OWNER AUTHORIZATION TO U COMPLETED WHEN OWNERS ARGENT OR CONTRACTOR APPLIES FOR BUI DING PERMIT 4_ `J� C �C 7 SS 6✓3 `t! 6 as OWWIAut)wnud Agent of subject properly Eby X0,i5 Sc �t £ , to on My , in to work 1a+tl►aimed by ibis twitding permit applicati S`------------ turyf 1)atc SECTION 7b O*NEWAUTHOPAW AGENT DECLARATION ,ea OwnedAut)arired Agent of subject Hereby declare that the statements and information on the foregoing application are tree and accurate, to On best of my knowledge and belief - Print Name Si of Owner/ bate 0.OF STCm SUE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONSOF•SW D24ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CMMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL OAS LINE VA W 9 w 0 z :1 c 0 me � o o � C +�+ O y C V C.3 •a'C CL. O A O C :Z O O � Ea c w.2 o o a y Ec w 0C w cm CD Nl W C �3 W > _� m C C � � � m y W y m mo a43 mm C O C yQ m O v yz co ao a `mc = m •�o o m� COD C w C o 'o a .. G CL CD h d •4D 0 � Os s w a 3 H m a a.Z..m E L. t s y c re caCMC m O CD C c s m 0 z O g O U) LIJA o� W W W N a O a a A a v E A a «� a WU :1 c 0 me � o o � C +�+ O y C V C.3 •a'C CL. O A O C :Z O O � Ea c w.2 o o a y Ec w 0C w cm CD Nl W C �3 W > _� m C C � � � m y W y m mo a43 mm C O C yQ m O v yz co ao a `mc = m •�o o m� COD C w C o 'o a .. G CL CD h d •4D 0 � Os s w a 3 H m a a.Z..m E L. t s y c re caCMC m O CD C c s m 0 z O g O U) LIJA o� W W W N I ne Commonwealth of Massachusetts Department of Industrial Accidents t ' AIT. 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):q<l?_ Cov,_,57-�.(j Address: City/State/Zip: "—/R,�_z tca b/ "Phone #:_7V-, Are Y_"an employer? Check the appropriate box: 1.[2 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. EJ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other mi out ine 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 job site information. Insurance Company Name: 3 i27 -, Policy # or Self -ins. Lic. #: 3 iS — 33) 3 70 — 0/ Expiration Date: L�_ Job Site Address:_ 7.3 Ci /State/Zi ty p Z%• /Sln-On� 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 9� insurance coverage verification. I do hereby pains and penalties of perjury that the information provided above is true and correct / - 6,,.D s/, - Official use only. Do not write in this area, to be completed by city or town official, City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Permit/License # 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 Other oflegal a deceased orany employer, or the re of the foregoing engaged in a Joint enterprise, and including the legalrepresentatives However the receiver or trustee of ab individual, partnership, association or other legal entity, employing employees. owner of a dwelling house having not more ian three rnements nconstruction orrepair resides therein, work on such dwelling house dwelling house of another who employs Persons to do maintenance, 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 rmance of public work until acceptable evidence of compliance with the insurance enter into any contract for the perfo requirements of this chapter have been presented to the contracting authority." Applicants Please fill out thew 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 so be sure to sign and ddustrial ate the ffidy be subn-dtted to the avit. tTheof affidavit should Accidents for confirmation of insurance coverag e. be returned to the citor 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' y artment at the number listed below. Self-insured companies should enter their compensation policy, please call the Dep 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 app ant that must submit multiple permittlicense 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 of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia 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: MA&LCry C r^-' — [r) (Location of - � t, --i 'T 015,003,1 C 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 id CO,q C -H, -h �,q-.S L ^-) 201 115" 86;tt 261--"f- 38" f All dimensions -sizc designations given arc This is an original design and must not be Designed: 4114/05.: subject to verification on job sits an released or copied unless applicable fic has Printed: 4/14/05 adjustment to fit job condition. . been paid or job order placed. .tc 4117 Date. ..... ..... ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ,,.. ......., .......%12 �/.................. �f iI �c�� ;� has permission to perform............................................................................. i ^�� �f r� wiring in the building of .......� ... ..............�................ ............................ at ........7 J..... a C* C !....!!?'!4 Vis.... .....��../orthAndoverass. ^3� ........... -� CCRICAL INSPECCOR( Check # / // TBECOAMONWEALTHOFA14`S'SACHUSEnS ffice Use only DEPAR7tYI 0FP1MUC,WL- Permit No. I BOARDOFMEPREVEMONREGUTAHONS527CM-12.VO Occupancy & Fees Checked APPUCATTON.FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, $27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date OIi j1 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) % 73 Owner or Tenant ztr r, Owner's Address Is this permit in conjunction with a building permit: Yes No 1:;y (Check Appropriate Box) Purpose of Building Utilit Authorization No. Existing Service c6 U Amps46 a.%/p Volfs Overhead --------Underground No. of Meters New Service Amps / Volts Overhead --�—�--- 0 Under round g No. of Meters Number of Feeders and Ampacity - Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers k1kto start� hWec6onRcugh Total No. of Lighting Fixtures Swimming Pool Above Below KVA Generators No. of Iteceptacle Outlets round No. of Oil BurnersEmergency round KVA Lighting Battery Units No. of Switch Outlets No. of Gas Bumers LicenseNo 3 3 3--,T to No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones No. of Disposals No. of Heat Total Tons Total No. of Detection and No. of Dishwashers Pumps Tons Space Area Heating KW KW Initiating Devices —signature Telephone No. No. of Sounding Devices or Owner or Agent No. of Self Contained No. of Dryers Detection/Sounding Devices No. `.Vater Heating Devices KW Local Municipal Other of Heaters KWConnections No. of No. of . No. Hydro Massage Tubs Si ns Bailasis No. of Motors Total HP DTHER• v �O0 / X r r Z ttcxCQ o v k �}t Oc1 S o-{ 5 6 imuanoeCovetage Ptasuat�6otherequrtanays GereralLaws ha�aaraaltLiabt-itykMrdwepbkymd&gCmip have cc)wwcritsablanuequivaler* YES NO submikd vandptoofof=rtD drCffice heddr9the YES r 7p Lam( Ifyouba edrdodYF�,p]M& ofm by box VSURANCE BOND" OTHER " (MmSpedY) k1kto start� hWec6onRcugh Esi nmbd VahredE1XtXal Work $ ignedunder-TrPmalr�ofP00T.. Fel RMNANM .411 4- e. VL-� � � z t, LimwNo. /SS LicenseNo 3 3 3--,T to BusirmTel No. 970,-7� 3 I-�/.FS- 9 Alt Tel Na. JVIII SINSURANCEWAIVEatthe R;IamawarethLimedoesnothavetheMA ranoecoverageOritssubstantial equivalartasregtraadbyMassadnr GerraalLaws 9thatmysigt,atrueonttrispeur>itapp) >����nt lease check one) Owner � Agent p \ 65", —signature Telephone No. PERMIT FEE $ d`��) or Owner or Agent N° 2367 Date.... ..... °`.``° '• .."° TOWN OF NORTH ANDOVER 0. p PERMIT FOR WIRING This certifies that .......................................................... has permission to perform wiring in the building of ......................I ..................................................... at . � �.......G��... �'�'� �....... , North Andover, Mass. Fee Lic. No. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE COMRION F,41,THOFARM(.YIU,SE77S Office Use only S DLPARTAfEWOFPUBUCSAFEIY Permit No. 6� BOARDOFFIREPRE[=ONREGUTAT70NS527CMRI2. iYJ Occupancy &Fees Checked ADPLICATIONFORPE?AITI'TOPERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Z (D Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. MAP PARCEL Location (Street & Number) -L ,JS LA . Owner or Tenant e`t cv, A-, L> =c,—s Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building. r��ti.� �-L� Utility Authorization No. Existing Service Amps �Volts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work i�-E No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above 0 Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No, of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OT4ER• �• � �n sir.• -r �:.0✓. •i Ii== /�(r h L r , kAAc'C S4Thae T IMM1,10 !. 1 e`er �, Bum=TeLNo. ' AkTeLNa IamawarethattheL=wdoesmtl,Aetheitaa=a aaWcritsatsWnbdcquA3htaso4madbyMassad�CxnaalLaws andtha rTsigmhmcnimpmi t waiwstllisregmiemat (Please check one) Owner Q Agent Telephone No. PERMIT FEE $ Signature ot Owner or Agent Location/ a 3 ( O d C- iin, ,V.1 JA V C-- No. YY Date Al_�3-bd TOWN OF NORTH ANDOVER F•- 1 _ - • L9 Certificate of Occupancy $ a E<�' Building/Frame Permit Fee $ 3 CRUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ y3' Check # 13741 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ...,., ......... .. ...... ...-.5. - .. BUILDING PERMIT NUMBER: / ` DATE ISSUED: SIGNATURE: e cwjw��� Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 PropertyAddress:l1 / 3 CtoaG 1.2 Assessors Map and Parcel Number: Map Number Parcel Number mber AVO ik � v©yrM 1.3 1.3 Zoning Information: Zoning Dis_v d Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re red Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 1.5. Flood Zone Information: 54) Public 0 Private 0 Zone Outside Flood Zone 1.8 Se a Disposal System: Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Na a (P nt) Address for Service SVatlre Telephone 2.2 Owner of Record: y Name Print Address for Service: • t Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: I\ VIA eAJ Licensed Construction Supervisor: 5 T1 Ce_v1 r n C �eG� �]-�h�l a 0�jgo Addr✓ J`T�d� c� J'' /� p /p [% 8 d t 5 O -( d Signature Telephone Not Applicable ❑ h10 (QQ License Number _�� Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone M M X Z O v rn I SECTION 4 - WORKERS COMPENSATION (XG.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 building it. Signed affidavit Attached Yes ...... 2' No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work:9 ," U') eA Y V IA 0 r [n 'I^ a etc c cau C _. 0, h 'C� lnn " VO o VV-, V\ P V o n Q' a) x18 S«0e- ?prc [I tN Ne�zr- -� f t ;�- F(4-� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building / y O( a J (a) Building Permit Fee Multiplier 2 Electrical /mcg. L © (b) Estimated Total Cost of Construction dt I v 3 Plumbing Building Permit fee X (b) / ��� s 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 , el,4 eb as OlAmer/Authorized Agent of subject property Herebv authorize to act on My be. It: afters elative to work authorized by this building permit application. Od SM ure o Ow7ter Date EC ION 7b OWNER/AUTHO ZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject Property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge . and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS I 2ND 3 RD SPAN DIMENSIONS OF SILLS M ENSIONS OF POSTS DMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE BUILDING DEPARTTHENI T DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Y- T (-Yr Ar t l /y G�,S' Z� 1 \ C�yhFP w. tnn Location of Facility Signa Permit Applicant i Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector f_ • A O The Commonwealth of Massachusetts Department of Industrial—cc;dcnts _ �>J Off ice or lnvesticatians \ = — Boston, Mass. 02 111 Wcrkers' Compensadcn Insurance Airrdavrt lNlame Plesse Print I G vi t�-,— '3 (—j I am a sole proprietor and have no one working in any czpa&y I am an empiever providing workers' compensation fcr my employees wcrkine an this job. Address CihrPhcne - Comcanv narne: Address Cihr: Phone :�' Insurance Co. Pclici t Failure to sec::re coverage as recuirec uncer Sec::en 2EA cr MGL 15_ can lead to the imposition d cnmiral penalties cr a fine up to S1.5CO.00 ander one years' imcrscrment as •.ve:l as c:vii penaRies in the f.crrn ct a STCP iNCRK CRCE.R and a fine ci (S,MCO) a day against me. I understand that a c !Zy d ;itis staement may to fcrvarcec to the Office d Investigations cf :he 01Afcr coverage verification. I do heretry c --w- under itre pains and penalties or perjury that :he infcrmaticn provided accve is .rve and correct. 3 1 0-0 9 Print hone' Q3g Sl��g8.4 Oftal use oniy . Co not write in this area to to ccmcletec ty c::y cr ;cNn cr:c:zi City cr Tcvn P=rmitll cer+sirc Building Dept ❑Check .f immediate resrcrse is required [I LiC�nsing `Card �j Selectman's O�1Ce Cenrac: ,person: Phcne T Health Department ❑ Other IV I �t6,.,C n M A I Phcne T �`I �S5 3 qI0 I am a homeowner performing all work myself. (—j I am a sole proprietor and have no one working in any czpa&y I am an empiever providing workers' compensation fcr my employees wcrkine an this job. Address CihrPhcne - Comcanv narne: Address Cihr: Phone :�' Insurance Co. Pclici t Failure to sec::re coverage as recuirec uncer Sec::en 2EA cr MGL 15_ can lead to the imposition d cnmiral penalties cr a fine up to S1.5CO.00 ander one years' imcrscrment as •.ve:l as c:vii penaRies in the f.crrn ct a STCP iNCRK CRCE.R and a fine ci (S,MCO) a day against me. I understand that a c !Zy d ;itis staement may to fcrvarcec to the Office d Investigations cf :he 01Afcr coverage verification. I do heretry c --w- under itre pains and penalties or perjury that :he infcrmaticn provided accve is .rve and correct. 3 1 0-0 9 Print hone' Q3g Sl��g8.4 Oftal use oniy . Co not write in this area to to ccmcletec ty c::y cr ;cNn cr:c:zi City cr Tcvn P=rmitll cer+sirc Building Dept ❑Check .f immediate resrcrse is required [I LiC�nsing `Card �j Selectman's O�1Ce Cenrac: ,person: Phcne T Health Department ❑ Other •12/09/99 THU 13:26 FAX 603 224 8011 ROWLEY AGENCY —.--..—.— . — — — Z 0 01 GATE (MMIODfM ,`,I„'="® 12106199 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER CONFERS NO RIGHTS UPON THE CERTIFICATE The Rowley Ageney, Inc. ONLY AND HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 511 Concord MN 08904.01111 INSURERS AFFORDING COVERAGE INSURER A 91. Paul sorplu•/Slu WSVRED INSURER B: Acadia Insurance Company Now England Builders 4 COnlraOters, Inc. 0eneral Spar Indainnity Contractors, Inc. INSURER C: 220 Broadway, gWta 107 INSUKR D: Liberty A/vlual Methuen AIA 01644 INSURER E: 1 NAMED ABOVE FOR THE 1000Y PERIOD INDICATED. NOTWITHSTANDING THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, eXCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN, THE INSURANCE AFFORDED MY DAlfl RF( hyr 1 LITg cunt/ . 1! BFFij RE1 UCED . P Y EiFECTTYE POLICY E7�IRATION LIMITS MSR POLICY NUMBER TYPE OF MSURANC� XG FOCCURRENCE t 1,000 000 A WgRAL LIABILITY SF05506808 10/13/99 10/13/00 FIRCRE DAMAGE (Any MA OIa i 50,000 X COMMERCIAL GENERAL LIAb41TY MADE D OCCUR MEO Eli (An i 5,000 CLAMS ADV kJRYown PER90PIAL t I►wRv S 1 000, 000 �--� DENERAL AGGREGATE i 2,000,000 MODUCTS - COMP/OP ADO i 1,000,000 • OETNL AGGREGATE LIMIT APPLIES PER: POLICY PR LOC . B AUTOMOBILELIABILTTY MAAISO042915 10/13/99 10/13/00 �`EDSINGLE LIMIT s 1,000,000 ANY AUTO ALL OWNED AUTOS BODILY 7UURY i (PN poison) X SCHEDLA.ED AUTOS X HIREDAUTOS ODDLY $WRY (Poi scolo,np i X I NON OVMEO AUTOS j11 PROPERTY DAAIAOE t yjl (Pei occadenq AUTO ONLY • EA ACCIDENT 6 GARAGE LIABILRY EA ACC i ANY AUTO OTHER THAN AUTO ONLY: ADO i EACH OCCURRENCE t 2,000,000 C EXCESS LAXITY IUG345647C X � OCCUR CLAMS MADE 10/13/99 10/13/00 AGGREGATE t 2,000,000 K t DEDUCTIBLE t RETENTION t WC $TATA 0 WORKERS COMPSASATION AND EMPLOYERS' LIABILITY WE13IS308361029 11/01/99 11/01/00 E.L. EACH ACCIDENT : 500 000 B E.L. DISEASE - Fa EMPLOYEE Is 500,000 E.L. DISEASE - POLICY LIMIT Is 500,000 OTHER DESCRIPTION OF OPERATION.A.00AT10N5NEHICLESEXCLU$06 ADDED BY ENDO198EMENT/SPECIAL PROVLSIONS Attesting to tiabitity coverages. For InlOn0s"onal Pu1"1104 Only ACORD 26-S (7/97) ^ANCELLATION — SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MNL 10 DAYS WRITTEN NOTICE 10 THE CERTIFICATE MOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL WPM NO OBLIGATION OR LIABILITY OF ANY KINO UPON THE *SURER, 1% AOENTS OR REPRESENTATIVUS. AUT}IORIZEO REPRE9(NTATIVE ' )i / (0 ACORD CORPORATION 1882 1121 HE .- A M E R I C A N I N S T I T U T E AIA Document A101 O F A R C H I T E C T S Standard Form of Agreement Between Owner and Contractor where the basis of payment is a STIPULATED SUM 1987 EDITION THIS DOCUMENT HAS IMPORTANT LEGAL CONSEQUENCES; CONSULTATION WITH AN ATTORNEY IS ENCOURAGED WITH RESPECT TO ITS COMPLETION OR MODIFICATION. The 1987 Edition of AIA Document A201, General Conditions of the Contract for Construction, is adopted in this document by reference. Do not use witb otber general conditions unless this document is modified. This document has been approved and endorsed by The Associated General Contractors of America. AGREEMENT made as of therPd end �- day ofr- � , in the year of BETWEEN the Owner: (Name and address) II Ri G � 'd I l � I 13 COO, C r—a n S L-G� e. N 1/ V I E A Y, © v t y- . and the Contractor. (Name and address) r J'5 cc,,A�r4. Sfi' S OhC'ka w\. The Project is: 'n,,�j (� ` (Name and location) S'(- r �� t?. r / (01'C t)(� V ` d ` I �y ✓� I`ll C�rvaL''r La�� The Architect is: 1� (Name and address) �A C.- L a r e h S.r o Cif o` Pe- S T vi e- 3 (0a:rn S�r-e-c- � P� h�o✓'e, M A The Owner and Contractor agree as set forth below Copyright 1915, 1918, 1925, 1937, 1951, 1958, 1961, 1963, 1967, 1974, 1977, ©1987 by The American Institute of Archi- tects, 1735 New York Avenue, N.W., Washington, D.C. 20006. Reproduction of the material herein or substantial quotation Of its provisions without written permission of the AIA violates the copyright laws of the United States and will be subject to Icgal prosecution. AIA DOCUMENT A101 • OWNER -CONTRACTOR AGREEMENT • TWELFTH EDITION • AIA• • 01987 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 A101.1987 1 WARNING: Unlicensed photocopying violates U.S. copyright laws and Is subject to legal prosecution. N t ARTICLE 4 CONTRACT SUM 4.1 The Owner shall pay the Contractgr in current funds or Contractor's pe otznance of the Contract the Contract Sum of Twp j - i -0"-a M or �) �( 1� �. ►� funds 2�i S I, t y h rc�-.----_.._._._ _ Dollars is r't� PJ �, on ), subject to/additions and deductions as provided in the Con. tract Documents. 4.2 The Contract Sum is based upon the following alternates, if any, which are described in the Contract Documents and are hereby accepted by the Owner: (State the numbers or otber identification of accepted alternates. If decisions on otber alternates are lobe made by the Owner subsequent to the execution of ibis Agreement, attacb a schedule of sucb otber alternates sbowing the amount for eacb and the date until wbicb tbat amount is valid.) � � y 4.3 Unit prices, if any, are as follows: ,,rW1 i �' -ems ped 67 oli„<r. AIA DOCUMENT A101 • OWNER -CONTRACTOR AGREEMENT • TWELFTH EDMON • ALA* • 01987 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 A101-1987 3 WARNING: Unlicensed photocopying violates U.S. copyright laws and is subject to legal prosecution. ARTICLE 5 PROGRESS PAYMENTS 5.1 Based upon Applications for Payment submitted to the Architect by the Contractor and Certificates for Pavment issued by the Architect, the Owner shall make progress payments on account of the Contract Sum to the Contractor as provided below and elsewhere in the Contract Documents. 5.2 The period covered by each Application for Payment shall be one calendar month ending on the last day of the month, or as follows: 61rjOC� CSPOr1 0, CC eplO0 C450 `1'a0 /Vla fe r) at I S �l ve ve 1683 � comp(c e) 5.3 Provided an Application for Payment is received by the Architect not lata than the day of a month, the Owner shall make payment to the Contractor not later than the day of the month. If an Application for Payment is received by the Architect after the application date fixed above, payment shall be made by the Owner not later than days aha the Architect receives the Application for Payment. 5.4 Each Application for Payment shall be based upon the schedule of values submitted by the Contractor in accordance with the Contract Documents, The schedule of values shall allocate the entire Contract Sum among the various portions of the Work and be prepared in such form and supported by such data to substantiate its accuracy as the Architect may require. This schedule, unless objected to by the Architect, shall be used as a basis for reviewing the Contractor's Applications for Payment. 5.5 Applications for Payment shall indicate the percentage of completion of each portion of the Work as of the end Of the period covered by the Application for Payment. 5.6 Subject to the provisions of the Contract Documents, the amount of each progress payment shall be computed as follows: 5.6.1. Take that portion of the Contract Sum properly allocable to completed Work as determined by multiplying the percentage completion of each portion of the Work by the share of the total Contract Sum allocated to that portion of the Work in the schedule of values, less retainage of percent ( %). Pending final determination of cost to the Owner of changes in the Work, amounts not in the dispute may be included as provided in Subparagraph 7.3.7 of the General Conditions even though the Contract Sum has not yet been adjusted by Change Order; 5.6.2 Add that portion of the Contract Sum properly allocable to materials and equipment delivered and suitably stored at the site for subsequent incorporation in the completed construction (or, if approved in advance by the Owner, suitably stored off the site at a location agreed upon in writing), less retaimge of. percent ( off,). 5.6.3 Subtract the aggregate of previous payments made by the Owner; and 5.6.4 Subtract amounts, if any, for which the Architect has withheld or nullified a Certificate for Payment as provided in Pam - graph 9.5 of the General Conditions, 5.7 The progress payment amount determined in accordance with Paragraph 5.6 shall be further modified under the following circumstances: 5.7.1 Add, upon Substantial Completion of the Work, a sum sufficient to increase the total payments to percent( %) of the Contract Sum, less such amounts as the Architect shall determine for incomplete Work and unsc[ticd claims; and 5.7.2 Add, if final completion of the Work is thereafter materially delayed through no fault of the Contractor, any additional amounts payable in accordance with Subparagraph 9.10.3 of the General Conditions. 5.8 Reduction or limitation of retainage, if any, shall be as follows: (/f it is intended, prior to Substantial Completion of the entire Work, to reduce or limit the retainage resulting from the percentages inserted in Subpara- grupbs 5.6. / and 5.6.2 abouv. and ibis is not explained e/seu*err in the Contract Documents, insert bere provisions for sucb reduction or limitation.) AIA DOCUMENT A101 • OWNER -CONTRACTOR AGREEMENT • TWELFTH EDITION • AIA* • ©1987 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 A101-1987 4 WARNING: Unlicensed photocopying violates U.S. copyright taws and is subject to legal prosecution. 9.1.7 Other documents, if any, forming part of the Contract Documents are as follows: (List here any additional documents tubicb are intended to form part of the Contract Documents. The General Conditions protide tbat bidding requirements sucb as advertisement or invitation to bid. Instructions to Bidders, sample forms and the Contractor's bid are not part of the Contract Documents unless enumerated in ibis Agreement. Tbey sbould be listed bere onto, if intended to be part of the Contract Documents.) This Agreement is entered into as of the day and year first written above and is executed in at least three original copies of which one is to be delivered to the Contractor, one to the Architect for use in the administration of the Contract, and the remainder to the Owner. OWNER (Signature) (Printed name and title) CONTRACTOR (Signature) 5r �arti (Printed name and title) CAUTION: You should sign an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced. nwi • VWNER•CONTRACrOR AGREEMENT • TWELFTH EDITION • AIAa • 01987 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W., WASHINGTON, D.C. 20006 A101-1987 8 WARNING: Unlicensed photocopying violates U.S. copyright laws and is subject to legal prosecution. 'y �-..iV1� �*J."�r'n.�d'^ ��% �f. ry (n •f, t.l�k�,ry,�. / -yN; 1 ✓ .�, `' BdI RD OF BL ILQING'R GUi;A71ONS. CbNSTRUCTION-SUPER�/ISOR License: Number •;CS 060600 i . Birthdi�te 12/01/1966 Expires:t2/01l2000 Tr. no: 5336 Restricted To: 00 i t ERNESTE RAMEY` 55 CENTRAL ST STONEHAM,. Adrri MA 02180 TniStrator FORM U - LOT RELEASE FORM Ii STiUCT10NS: This farm is used to verify that all nec=essary approvals/permits from- Eeards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. .,k"APPLICANT FILLS OUT THIS APPLICA�aT Fr v\ c l� inn X"P HCNE LOCATION: AsS2ssces Map Number �JFARCE_ SUEDIVISICN ( LOT (S) STREET CO'CL rile urn o v\ S L Q h e_ (16T. NUNISE:R � OFF ICIAL USE ONLY .... REC.OMMENDA T IONS OF TOWN AGENTS:. I CONSERVATION ADMINISTRATOR �n COMMENTS�N�4 TOWN P NE i COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED - (e_ Ce•.5 DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUELIC WORKS - ScNEFJWATER CONNECTIONS CRIVE'NAY PERMIT FIFE DEPAR T NIENT REC'ivc7_� EY SUILDiNG iNSPEC T C Revised 5*,S im DATEE Cl) m m m VJ 0 y CD � z CD O ar � d CD Q =. a� � O o p C� c ,c CP CD ... Q O to CD 0 CO) "0 CD Cl) O CO) d d O CO) .0 c 0 CO) c� CD O �F CD CD y. CD CO) O V V J 0 cn c?�O m 2 Q y FL O C m N CL m n p rm„e�ao � � Z --4 0 .=rte wm CO) m dCL Fn id CO) m O m CO) wo O `4 O =' m tA m mcl O Z5•n . 1 O H n aO -&o O c Er_ kCL'"..: U2 O ?CD , 0 CD _.� .:� ..� H O H H dd �C C c o OD CO) CL � CD wom y CO) m CD CD a) y L 3 = CD � V1 m w: 0 * M C=., H .-► CCD, � m VI)=mw. O c CD m _ a�rm o` _ 2oa = CD Q►:� ;41 rD° r 0 O 0 C COD z 5 w 0_�0 C b ?, G 0 c 0 r 0 rD O 1) 0 c