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Miscellaneous - 173 INGALLS STREET 4/30/2018
N O � V O W rs Z 1 b O cn CP co Om O m PM Location Wel Date r P TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ r io Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I Check #�' r 30638 Commonwealth of Massachusetts Sheet Metal Permit Date Estimated Job Cost: Plans Submitted: YES NO X Business License # 04 Uo Z 7 �q5 Business Information: A Name: 0Arma�l VAGlAId- Street: -City/Town: W d b orn nil9- ®I Sa Telephone: — 9,&_rj— Q/ A - Permit # ✓�� �� Permit Fee: $ Plans Reviewed: YES.' NO, Applicant License #0Ci 100c) 9.�� Property Owner / Job Location Information: Name: M/92i P C� 0 A k L -_r _ Street: _ 17,3 /qtr C R I Is �S 7- City/Town: Al, A W dO U& & -WA Telephone: 9 Ie e of S6 b 6131" Photo I.D. required / Copy of Photo I.D. attached: YES v-- NO Building Type: Residential: 1-2 family V _ Multi -family Condo /-Townhouses Commercial: Office` " ''Retail Industrial Educational ' " �Institutional- Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: nf�� Renovation: HVAC _Z Metal Roofing Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 992 Yeses No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy W Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 912 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 Owner's Agent By checking this boxn, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title . ❑ Master -Restricted / City/Town ❑Journeyperson Permit # ❑Journeyperson-Restricted Fee $ ❑ RErb : d Adtacr Inspector Signature of Permit Approval Signature of Licensee License Number: AL ®© O� Check at www.mass.gov/dpl Sheet Metal Commercial Guidelines / Life Safe / Critical Systems Inspection Checklist Yes No N/A, .ti Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metalwork onsite has valid Massachusetts sheet metal license Yt-A All sheet -metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampets with access doors properly installed •- actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) AN Smoke / atrium exhaust systems installed and operation verified (May, also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) ' r, Grease /kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper 6161`ances, fire rated enclosures and pressure testing required: _ „ • . R ..Seisrrpv es�,.aiat� installed Q ibxftequired 'oft equipment acrd du v. r� WOO— Duct penetrations in fire-rated-%'all:3 and floors sealed ^ Metal roofing systems installed watertight using proper materials and fasteners Flexible duct runs installed 6'•-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle / iron - Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testina and Balanciney renort complete (final sien-off) Sheet Metal Residential Guidelines / Insvection Checklist x''es 1Vo N/A Detailed description and sketch of sheet metal system to be installed has Ih- been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metalwork being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations IA—Bath /shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0" maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight f Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign -ofd Name The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street, Suite 100 .`, Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE TILED WITH THE PERMITTING; ATrrrrnurTV Address: 3 13 YmJ A ye , City/State/Zip:_k)_d b o r a, 1 D/ 0 0) b I Phn,P fi• i� I g�'(Ij'•-D 7% 7 Are you an ployer7 Check the appropriate box: 1. am a employer with --LO employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. poo workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. .152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. E] Remodeling 9. {] Demolition 10 ❑ Building addition 11.[] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. n Roof repairs 14. X Other e t) 4k untc P V CT Ve5C — .---- •• ,,,,,. R, "'MA a b. rar our 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 state whether or not those entities have employees. If the sub=contractors have employees, they must provide their workers' comp. policy number. I am all employer that is providing workers' compensation insurance for my employees. Below is the policy and job site inforuration. Insurance Company Name: �> /`6R & 7-1,_ y� so Policy # or Self -ins. Lic. #: Yt/ , VExpiration Date: e Job Site Address: 3 l S' OdYlstate/Zip: -A01'a Attach a copy of the workers' compensation policy eclaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of coverage verification. Investigations of the DIA for insurance I do hereby certr' under the pains s ofpeijuiy that the information provided above is true and correct. int /) �� e'i.�stirn Official use only. Do not Write in this area, to be completed by city or town official City or Town: Permit/License # I ssu►ng Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town;Clerk 4. Electrical Insp 6.Otherector 5. Plumbing Inspector . 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 a "an individual, partnership, association, corporation or other legal entity, oranytwo 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 iridividual, 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 Ball 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 liccrses. 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE - Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia (9- V&ri r) 'I CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFIC7/12/2016 HOLDER. THISATE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE BY THE POLICIES AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTNA EACT Barbara McDonough Gilbert Insurance Agency, Inc. PHONE (781)942-2225 Fax AIC No): (781)942-2226 137 Main Street A AlRL-bmcdonough@gilbertinsurance . com cn o sir........{ - - ----F NAIC Reading , MA 01867-3922 INSURERA:SafetCompany Insurance INSURED394$4 Lohrman Hvac, Inc. INSURER B:Gra hic Arts Mutual Ins Co 25984 3 Breed Ave. # C INSURER C: INSURER D: Woburn MA 01801 INSURER E: INSURER F: COVERAGES -- — — — -- ------------ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO KGVISIUN NUMBER: THE INSURED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE WHICH THIS POLICIES DESCRIBED HEREIN IS SUBJECT TO EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED ALL THE TERMS, INSR BY PAID CLAIMS. A D SU R LTR TYPE OF INSURANCEINSO VdVnPOLICY NUMBER MM/DDY MOLIC EXP LIMITS X COMMERCIAL GENERAL LIABILITY A CLAIMS EACH OCCURRENCE —RENTED $ 2,000,000 MADE OCCUR PREMISES Ea occu $ 100,000 BMA0019178 3/15/2016 3/15/2017 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- � LOC GENERAL AGGREGATE $ JECT PRODUCTS - COMP/OPAGG $ 4,000,000 OTHER: Employee Benefits $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000"000 A ANY AUTO ATOSCHEDULED BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ AUUTOSS AUTOS 6222671 COM 03 3 15/2016 / 3/15/2017 X HIRED AUTOSX NON -OWNED AUTOS PROPERTY DAMAGE $ X Per accident PIP -Basic $ 8,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE - B OFFICERIMEMBER EXCLUDED? ❑ N / A E.L. EACH ACCIDENT $ 500,000 (Mandatory In NH) if yes, describe under 4444501 7/30/2015 7/30/2016 E.L. DISEASE - EA EMPLOYE $ 500,000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ Soo,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space Is required) Project: installing Mitsubishi A/C systems. Customer: Ms. Maria Guarini, 173 Ingalls Street, N. Andover, MA 01845. CFI?TICIrATC unr non - — ---- I.ANL;LLLAIION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of No. Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA I ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE M Gilbert, CIC/BARBAR ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 nnl4nn Commonwealth of Massachusetts . Department of Public Safety License: RC -000953 Refrigeration Contractor WILLIAM J LOHRMAN 18-R HILLSIDE WAY WILMINGTON MA 01887 �-J--M CA— Expiration: Commissioner 12/03/2017 0 co O icy/ CA ; LO W 0 s��� 0 W CO LL oN 0 < o rq Date ..... . ........... / ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... . ..... 6...6.k . .......... has permission to perform ....... .. .... C. .... .............. wiring in the building of ....... r- 144 K AJ) ... r ................................................................................................... at .... 1.13 J -;u c, C -5 . ................ .............. ....... 5 .......................... r ............. . North Andover, Mass. ............................ ... . .......... Lic. No . .... : a W ,Feea ........... ELECTRICAL INSPECTOR Check# 3� S-3 13021-/ 4e Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 (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 ININK OR TYPE ALL INFORMATION) ! Date: 01"W6 City or Town of. NORTH ANDOVER 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)_( � 3 54 Owner or Tenant Mark A kpA � G oe rlr►j Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes '� No ❑ (Check Appropriate Box) Purpose of Building DW00 %!N Utility Authorization No. - Existing Service00 Amps o /yv Volts Overhead Er Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: QJ p o 3I o S ',s 1 n tvi re;ii 1-1 A4, 4ran,'r- To c, Kic k he.44 Yrs 2 17re'J-e sed 6t-&61 /z -,T,aek Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires p2 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In El rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste DisposersTotals: eat um umber ons Tl KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW . Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of fres. Estimated Value of Electrical Work: p�, oo d (When required by municipal policy.) Work to Start: f .6 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: 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 cover cis in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Icertify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ onl Z eC LIC. NO.: 41 6 3 Licensee: J&vI R fel (A Signature LIC. NO.: jag 4( '9 (If applicable enter "e empt" in the license number line.) , Bus. Tel. No. • .& 1 it � � 3 e Address: _ g 3 iri VY -I In 84 St net d, (je IVA - D�(` / 145 Alt. Tel. No. *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement: I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PUMIT FEE: $ � O� Signature Telephone No. ) ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the - notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass EN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass [N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSP TION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 4.4 Inspectors Signature: Date: (FINAL INSPEC ION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: r—A DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com a ELI:T+GI AN'.5 s` F , BOARMOF I SSUES FO THE L.L6w'i,k "!,C'EN E r AS,Aa lZG ;JOURNEYMAN" €LECT�RI AfL PERE IRA " 10BERKSHwIRE 'ST t �, fAGR9I�I�E,'�M$« em -A 02141 1,902' , „41e28 1 0/31 / lf6 81.0.38 .:a i*riT�1L� TLSOF YcT T.i�. "x?Y3 2717 ft7rl�iiT5r7 ' �?l.3l iSif S€:lia 7 The Commonwealth of Massachusetts ^.. Department of IndustrialAccidents I Congress Street, Suite 100 Boston, HA 02-114-2017 < www.mass.gov/dia 0M s+V yParkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. �, ^ ^ ^ ^„;„� 1 Name (Busi.Hess/Oiganization/lndividual) : G Address: `A City/State/Zip: S avne A 0 1 S Phone #: 1® td Are you an employer? &eckct�he appropriate box: i. T am a employer with employees (frill and/or part-time).* 2•❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.E]I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contract6ts either have workers' compensation insurance or are sole proprietors with no, employees. 5. ❑T am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub contractors have employees and have workers' comp. insurance -I 6, Q We are a corporafioii and its, officers have exercised their right of exemption per MGL c.. 152, §1(4), and`we kava no employees`- [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: Homeowners who submit•this a%davrt indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ,: 1 Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Type of project (�egft ired)-' 7. ❑ Nevsi'constxuoiion 8. [] Remodeling 9. ❑ Demolition 10 [] Building addition 1 LEI Elec#ical repays or additions 12 ;tie 'Plumbing repairs` or additions 13•. J Roof repairs 14.Other Insurance Company Name: Expiration Date: Policy # or Self -ins. Lic. #: 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 required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby c fy and r the pains and penalties of perjury that the information provided move is true and, correct. �/„�fo. �fI3)Iro 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Inform.ation 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 trusted 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 notproduced -acceptable evidence of compliance with the insurance coverage ie quiiced:' 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 thi's 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 certificates) 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 fndustrial-Accidents. Should you have any questions regarding the law or if you are required to obtain a i i &kers' compensatioii 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia Nationall General Auto, Homo & Health4rtt=Mr_,L PO Box 1623 Winston-Salem, NC 27102 October 22, 2015 Town of North Andover Building Inspector's Office 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Claim Number: 1930026 Date of Loss: 10/13/2015 Insured: Mark & Maria Guarini Loss Location: 173 Ingalls Street Underwriting Company: Massachusetts Homeland Insurance Company Policy Number: PHDO067113NI301 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1000 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of this writer and include a reference to the above -captioned insured, location, policynumber, date of loss and claim number. On this date, I caused copies of this notice to be sent to the persons named above at the address indicated above by first class mail. SLI Ma k,Chav'pP,v�t�,r Signature: Mark Charpentier, Property Claim Specialist 314-813-2916 National General Insurance PO Box 1623 Winston Salem, NC 27102-1623 �j [[ M- r oS7 No- 2652 TD^ 0055 Date f NORTH 1 o?°•,�`"-:' ."�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that as n �vF� '���'ti C -- ...................................................... r.............................. has permission to perform &. S... ��' ��.N ......................:.................. .................... wiring in the building of .. ....................................... ........................ ate, .....�. �h? L�-... �� , North Andover, Mass. J �..-3.......... 7 Feea2 �' ............ Lic. No fi 7................................................................ ELECTRICAL INSPECTOR 4 Check # .31E, WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 0� Idc�S3 Official Use Only Permit No. Rc�l Sa6e�y Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 i� C-1% —=:5In-oZ5'�= APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number-3�1.gGti`—S 5—f Owner or Owner's Is this permit in conjunction with a building Purpose of Building J l t Existing Serviced Yes ", 4voits No ❑ (Check Appropriate Box) Authorization No. Overhead C� ' Undgrnd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity t'.1/ / /^ e Sew ", P-1-- Location Z---Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot fuse Total No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency -Lighting No. of Receptacles Outlets. No. of Oil Burners Batte Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Initiating Devices No. of Ranges Total No of Air Cond Tons Heat Total Total No. of Di osal No. Pumps . Tons KW No. of Sounding Devices No./ of Self Contained Detection/Sounding Devices r ' No. of Dishwashers Space/Area HeatingKW No. of Dryers Heating Devices KW ❑ Municipal ❑ Other Local Connection No. of No. of Low Voltage No. of Water Heaters KW Sims Bailases Winn No. Hydro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND = OTHER = (Please Specify) ) Estimated Value of Electrical Work$ Aa// (Expiration D Date � � n Work to Start Inspection Date Resquested Rough r/ Final Signed underth Pe alties of perjury: C FIRM NAMEjs� / /,/ — L v'C L LIC. NO. + U ✓" Lkensee k I / an—/�` C., �P7` 1'1 e j^ Signature LIC. NO. Bu6s. Tel No. 78-11' -6 3 s 3 Address �" r� �- Alt Tel. No. OWNER'S INSURANCE WAIVER: I aware that the Licenses does not have the insurance coverage oris substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner I Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMITTEE $ �� U.S. DEPARTMENT OF HOMELAND SECURITY -FEDERAL EMERGENCY MANAGEMENT AGENCY O.hf R wo.166o-Dols COMMUNITY ACKNOWLEDGMENT FORM FapiresDecember J1, 2010 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 1.38 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears.in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington DC 20472, Paperwork Reduction Project (1660-0016). Submission of the form is required to obtain or retain benefits under the National Flood Insurance Program. Please do not send your completed survey to the above address. This form must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request to remove a property from the SFHA which was previously located within the regulatory floodway (complete Section B). This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the subject property address must appear in the spaces provided below. Incomplete submissions may result in processing delays. Community Number, Property Name or Address:. A. REQUESTS INVOLVING THE PLACEMENT OF FILL As the community official responsible for floodplain management, i hereby acknowledge that we have received and reviewed this Letter of Map Revision Based on Fill (LOMB -F) or Conditional LOMR-F request. Based upon the community's review, we find the completed or proposed project meets or is designed to meet all of the community floodplain management requirements, including the requirement that no fill be placed in the regulatory floodway, and that all necessary Federal, State, and Iota[ permits have been, or in the case of a Conditional LOMB -F, will be obtained. In addition, we have determined that the land and arty existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c), and that we have available upon. request by DHS -FEMA, all analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS -FEMA for a possible map revision. For LOMR-F or Conditional LOMR-F requests that have the potential to, impact an endangered species, documentation will be submitted to show that we have complied with Sections 9 and 10 of the Endangered Species Act (ESA). Section 9 of the ESA prohibits anyone from "taking" or harming an endangered species. If an action might harm an endangered Species, a permit Is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA. For actions authorized, funded, or being carried out by Federal or State agencies, documentation from the agency showing its compliance with Section 7(a)(2) of the ESA will be submitted. Community Comments: Community Official's Name and Title: (Please Print or Type) Telephone No.: Community Name: Community Official's Signature: (required) Date: t`F11 ISfF' As the community official responsible for floodplain management, 1 hereby acknowledge that we have received and reviewed this request for a LOMA. We understand that thissequest is being forwarded to DHS -FEMA to determine if this property has been inadvertently included in the regulatory floodway. We acknowledge that no fill on this property has been or will be placed within the designated regulatory floodway. We find that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements. - LAY c r�'L wTf\SP:e 4-,� 95�� r;ix sS( urred)::.. rte:. Kx N0(17n4a vt!,4- I'\ DHS - FEMA Form 81-878, DEC 07 Community Acknowledgment Form MT -1 Form 3 Page 1 of 1 U.S. DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY 1, O.M.& NO.1660-0015 COMMUNITY ACKNOWLEDGMENT FORM ErpirmDecember31,2010 PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this fort is estimated to average 1.38 hours per response. The burden estimate includes the lime for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears.in the upper right comer of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, U.S. Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington DC 20472, Paperwork Reduction Project (16604015). Submission of the form is required to obtain or retain benefits under the National Flood Insurance Program. Please do not send your completed survey to the above address. This form must be completed for requests involving the existing or proposed placement of fill (complete Section A) OR to provide acknowledgment of this request to remove a property from the SFHA which was previously located within the regulatory floodway (complete Section 8). This form must be completed and signed by the official responsible for floodplain management in the community. The six digit NFIP community number and the subject "property address must appear in the spaces provided below. Incomplete submissions may result in processing delays. Gommunity Number. Property Name or Address: A. REQUESTS INVOLVING THE PLACEMENT OF FILL As the community official responsible for floodplain management, i hereby acknowledge that we have received and reviewed this Letter of Map Revision Based on Fill (LOMR-F) or Conditional LOMR-F request. Based upon the community's review, we find the completed or proposed project meets or is designed to meet all of the community floodpiain management requirements, including the requirement that no fill be placed in the regulatory floodway, and that all necessary Federal; State, and local permits have been, or in the case of a Conditional 0MIR-F, will be obtained. In addition, we have determined that the land and any existing or proposed structures to be removed from the SFHA are or will be reasonably safe from flooding as defined in 44CFR 65.2(c), and that we have available upon. request by DHS -FEMA, all analyses and documentation used to make this determination. For LOMR-F requests, we understand that this request is being forwarded to DHS -FEMA for a possible map revision. For LOMB -For Conditional LOMR-F requests that have the potential to impact an endangered species, documentation will be submitted to show that.we have complied with Sections 9 and 10 of the Endangered Species Act (ESA). Section 9 of the ESA prohibits anyone from "taking" or harming an endangered species. If an action might harm an endangered species, a permit Is required from U.S. Fish and Wildlife Service or National Marine Fisheries Service under Section 10 of the ESA. For actions authorized, funded, or being carred out by Federal or State agencies, documentation from the agency showing its compliance with Section 7(a)(2) of the ESA will be''submitted. Community Comments: Community Official's Nam and Tette: (Please Print or Type) Telephone No.: Community Name: Community Official's Signature. (required) Date: As the community official. responsible for floodplain management, I hereby acknowledge that we have received and reviewed this request for a LOMA. We understand that this request is being forwarded to OHS -FEMA to determine if this property has been inadvertently included in the regulatory floodway. We acknowledge that no flit on this property has been or will be placed within the designated regulatory floodway. We find that the completed or proposed project meets or is designed to meet all of the community floodplain management requirements. -- '—t t /Z i j1 IL.,,n",-- DHS - FEMA Form 81-8713, DEC 07 Community Acknowledgment Form MT -1 Form 3 Page 1 of 1 U.S. DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE OMB No. 1660-0008 Federal Emergency Management Agency Expires February 28. 2009 National Flood Insurance Program Important: Read the instructions on pages 1-8. SECTION A -PROPERTY INFORMATION 11 For In urance Company Use: Al. Building Owners Name roncy NumDer MARIA L, GU.4121 A2. Building Street Address (including Apt, Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Company NAIL Number l -?3 . Xlv G 4LL5 57, 1 d city A10 2?N AA -;n oV Lt? Nj A state 23P Code _ 0/1995- A3. 895 A3. Property Description (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) T r,rn rX My -t ) q Q lPa Q 9 PL.4 to R 6 S Y L o T 2 A4. Building Use (e.g., Residential, Non -Residential, Addition, Accessory, etc.) R CS 1 D T'1 K) L A5. ' Latltuda/L"Nudo: Lat 2 ° - 3 8 5 G • 1 ° tong. 0-1 1 - 03 - O Q . 6 " Horizontal Datum: ❑ NAD 1927 R NAD 1983 A6. Attach at bast 2 photographs of the building if the CedlNcato is being used to obtain food Insurance. A7. Building Diagram Number_ A/0 0 PL-_ hJ f N 6 S A8. For a building with a crawl space or ancloscire(s), provide: A9. For a building with an attached garage, provide: a) Square footage of Bawl space or enclosure(s) sq ft a) Square footage of attached garage 6 8 G sq ft b) No. of permanent flood openings in the crawl apace or b) No. of permanent flood openings In the attached garage enclosure(s) walls within 1.0 foot above adjacent grade walls within 1.0 foot above adjacent grade c) Total net area of flood openings In A8.b sq in c) Total net area of flood openings in A9.b sq in SECTIONS -FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP Community Name & Community Number 82. County Name B3. State -AloraT T)OVLR 7_50 919 1 LS5V_"( B4. Map/Panel Number85.`Sufflx Top of bottom floor (including basement, crawl space, or enclosure floor) B6. FIRM Index B7. FIRM Panel B8. Flood B9. Base Flood Elevation(s) (Zone \ �--❑ _❑ feet meters El meters (Puerto Rico only) Date Effective/Revised Date Zones) AO, use base Hood depth) 000 C ,uNIL 2 VN3 juin Z 1993 A l iZ• 9 B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item B9. ❑ FIS Profile ❑ FIRM .❑ Community Determined ® Other (Describe) G 0 h x1 L A SL -f O Li -6/ -02 50 A B11. Indicate elevation datum used for SFE in Item B9: EINGVD 1929 ' ❑ NAVD 1988 ❑ Other (Describe) B12. Is the building located Ina Coastal Barrier Resources System (CBRS) area or Otherwise Protected Area (OPA)4 ❑ Yes a( No Designation Date ❑ CBRS ❑ OPA SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Constriction' ® Finished Construction 'A new Elevation Certificate will be required when construction of the building Is complete. C2. Elevations - Zones Al -A30, AE, AH, A (with BFE), VE, V1430, V (with BFE), AR, AR/A, ARAE, AR/A1-A30, AR/AH, AR/AO. Complete Items C2.a-g below according to the building diagram specified in Item A7. Benchmark Utilized R M 10 ltl.lrV 111- 1L41 FI R M M A -P Vertical Datum Conversion/Comments Fu R N 4 c.Ls 5 1-} O T 1.1�1r}-iLr R �TKi ^1 K Check the measurement used. a) Top of bottom floor (including basement, crawl space, or enclosure floor) 115 .6 © feet 13 feet ❑ meters (Puerto Rico only) ❑ (Puerto Rico only) b) c) Top of the next higher floor Bottom of the lowest horizontal structural member (V Zones only) \ �--❑ _❑ feet meters El meters (Puerto Rico only) d) Attached garage (top of slob) El feet ❑motors (Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building X16 O [:]feet ❑ motors (Puerto Rico only) 0 (Describe type of equipment in Comments) Lowest adjacent (finished) grade (LAG) feet motors (Puerto Rico only) g) Highest adjacent (finished) grade (HAG)jig .4_0 feet J ❑motors (Puerto Rico only) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation Information. I cerH/y that the Inibrmadon on this Certificate represents my beat efibris to interpret the data available. I understand that any false statement may be p nhOmd le by tine or imprisonment under 18 U.S. Code, Section 1001. IN OF Check here if comments aro provided on be* of form. I-7 FX t_ 1 Certifiers Name J[A M f 5 D A A Q License Number 7 0-3 x ;: Title Q W CN zc R l Company Name Ho 6 u R L/ )J �ggt�pv Address (52 C%Z►� lcL% ' `T)RACUT state -�,,� ZIP Code 4!$26 Signature A, Date► 7 _.7_ �8 9 Telephone FEMA Form 81-31, February 2006 See reverse side for continuation. Replaces all previous editions IMPORTANT: In these spaces, copy the corresponding information from Section A. For Insurance Company Use: StdIding Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number /-7-� :MQ GALLS S-'. Stat ZIP Code �. Company NAIC Number c�iV o 2 -r /a A N I) ay (� iz 7 P 01 Z(5 SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both skies of this Elevation Certificate for (1) community official. (2) insurance agentkompany, and (3) building owner. Comments s v !rL'f- pR v P LR-ty L A_G 115.5 (5 2 . 41 G 1-} �.rz 7-4 � 1✓ 1✓C 1 VL 9-T4•KL-N �RoM LvMA C -ASL oy -lb -OZSa � 3oT�} ��L� 1N Lf sl4mL ATZcrR AND oNLy k000' A6'a2.7 Signature U, --n 0 t'IIA, Lame I 1 / -LZ /a 9 MCheck here 9 attachments SECTION - BUILDING ELEVATION INFORMATION (SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A (WITHOUT BFE) For Zones AO and A (without BFE), complete Items E1 -E5. ff the Certificate Is Intended to support a LOMA or LOMWF request, complete Sections A, B,_ and C. For Items E1 -E4, use natural grade, N available. Check the measurement used. In Puerto Rioo only, enter meters. El. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade (HAG) and the lowest adjacent grade (LAG). a) Top of bottom floor (including basement, crawl space, or enclosure) is _ ❑ feet ❑ meters ❑ above or below the HAG. b) Top of bottom floor (including basement, crawl space, or enclosure) is — ❑ feet ❑ meters ❑ above or below the LAG. E2. For Building Diagrams 6-8 with permanent flood openings provided in SecdqALA Items 8 and/or 9 (sees 8 of Instructions), the next higher floor (elevation C2.b in the diagrams) of the building is . _ [:]feet meters [:]above or LJp" the HAG. E3. Attached garage (top of slab) is ❑ feet ❑ meters ❑ above or ❑ below the HAG. E4. Top of platform of machinery and/or equipment serAcing the building is _ ❑ feet ❑ meters ❑ above or ❑ below the HAG. E5. Zone AO only. N no flood depth number is available, Is the bop of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes ❑ No ❑ Unknown. The local official must certify this information in Section G. SECTION F - PROPERTY OWNER (OR OWNER'S REPRESENTATIVE) CERTIFICATION The property owner or owner's authorized representative who completes Sections A, 8, and E for Zone A (without a FEMA -issued or community -issued BFE) or Zone AO must sign here. The statements in Sections A, 8, and E are correbt to the best of my knowledge. Property Owner's or Owners Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments ❑ Check here if attachments SECTION G - COMMUNITY INFORMATION (OPTIONAL) The local official who Is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A. B, C (or E), and G of this Elevation Certificate. Complete the applicable items) and sign below. Check the measurement used In Items G8. and G9. G1. ❑ The Information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor, engineer, or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data to the Comments area below.) G2. ❑ A community official completed Section. E for a building located in Zone A (without a FEMA -Issued or community -issued BFE) or Zone AO. G3. ❑ The following information (items G4. -G9.) is provkled for community floodplain management purposes. G4. Permit Number I G5. Date Permit Issued I G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been Issued for. ❑ New Construction ❑ Substantial Improvement G8. Elevation of as -built lowest floor (including basement) of the building: ❑ feet ❑ meters (PR) Datum G9. BFE or (in Zone AO) depth of flooding at the building site: ❑ feet ❑ meters (PR) Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑ Check here if attachments FEMA Form 81-31, Febnrary 2006 Replaces all previous editions Building Photographs Continuation Page For Insurance Company Use: Building Street Address (including Apt, Unit, Suite, andlor Bldg. No.) or P.O. Route and Box No. Policy Number TAjG A LLs City State ZIP Code CampenyNWMwnber I/O 2 7' /-1 A AN p CuL e M A If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." ` e - l f , - �._. Building Photographs See Instructions for Item A6. For Insurance Company Use: Building Street Address (including Apt, Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. Policy Number /-7 3 4 L& s s -r. city �. Alo n -rlq A>uV ovLR State M oZIP S44S' CamperryMAIC Number If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page, following. r72 7T VI LW i Fr2aA --7 V►LS: W r -z '4 M Z QWE- TV Y �J Pa. e 1 of 2 Date: June 10, 2004 Case No.: 04-01-0250A LOMA ' 0�4A%1F•1• Federal Emergency Management Agency N. o Washingtl,n, D.C. 20472 ND 5�c'J LETTER OF MAP AMENDMENT DETERMINATION DOCUMENT (REMOVAL) COMMUNITY AND MAP PANEL INFORMATION LEGAL PROPERTY DESCRIPTION TOWN OF NORTH ANDOVER, ESSEX Lot N, Crossbow Lane, as described in the Deed, recorded in Book 1820, COUNTY, MASSACHUSETTS Page 10, filed on June 8, 1984, by the Register of Deeds, Essex County, COMMUNITY Massachusetts COMMUNITY NO.: 250098 NUMBER: 2500980009C NAME: TOWN OF NORTH ANDOVER, AFFECTED MAP PANEL ESSEX COUNTY, MASSACHUSETTS DATE: 0610211993 FLOODING SOURCE:'UNMWED'PONOIRG AREA APPROXIMATE LATITUDE 3 LONGITUDE OF PROPERTY: 42.646,-71.054 SOURCE OF LAT S LONG: PRECISION MAPPING STREETS 6.0 DATUM: NAD 83 DETERMINATION OUTCOME 1% ANNUAL LOWEST LOWEST WHAT IS CHANCE ADJACENT LOT LOT BLOCK/ SUBDIVISION STREET REMOVED FLOOD FLOOD GRADE ELEVATION SECTION FROM THE ZONE ELEVATION ELEVATION (NGVD 29) SFHA (NGVD 29) (NGVD 29) N _ _ 10 Crossbow Lane Residential Structure X (unshaded) 112.9 feet 115.0 feet Special Flood Hazard Area (SFHA) -The SFHA is an area that would be inundated by the flood having a 1-percent chance of being equaled or exceeded in any given year (base flood). ADDITIONAL CONSIDERATIONS (Please refer to the appropriate section on Attachment 1 for the additional considerations listed below.) PORTIONS REMAIN I N THE SFHA ZONE A This document provides the Federal Emergency Management Agency's determination regarding a request for a Letter of Map Amendment for the property described above. Using the information submitted and the effective National Flood Insurance Program (NFIP) map, we have determined that the structure(s) on the property(ies) is/are not located in the SFHA, an area inundated by the flood having a 1-percent chance of being equaled or exceeded in any given year (base flood). This document amends the effective NFIP map to remove the subject property from the SFHA located on the effective NFIP map; therefore, the Federal mandatory flood insurance requirement does not apply. However, the lender has the option to continue the flood insurance requirement to protect its financial risk on the loan. A Preferred Risk Policy. (PRP) is available for buildings located outside the SFHA. Information about the PRP and how one can apply is enclosed. This determination is based on the flood data presently available. The enclosed documents provide additional information regarding this determination. If you have any questions about this document, please contact the FEMA Map Assistance Center toll free at (477) 336-2827 (877-FEMA MAP) or by letter addressed to the Federal Emergency Management Agency, P.O. Box 2210, Merrifield, VA 22116-2210. Additional information about the NFIP is available on our web site at http://www.fema.gov/nfip/. Doug Bellomo; P. ., CFM, Acling Chief Version 1.3.4 Hazard Identification Section, Mitigation Division Emergency Preparedness and Response Directorate 62174303 0300640516YOE00003006405 Live Search Maps , Print this page in a more readable format: Click Print next to the upper -right corner of the map. Location result for 171 Innallc St Nnrth Anr rwimr MA n1 Rd-R_RRdti L Page 1 of 1 Z o M A G 4,5-4f -4 ® `f •- d/ , 6 2 0 /' http://maps.live.com/ 1/22/2009 LAP7,sATI EPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.S NO.1660-0037 CON FORM FOR SINGLE RESIDENTIAL LOT OR STRUCTURE AMENDMENTS TO E 30, 2010 NATIONAL FLOOD INSURANCE PROGRAM MAPS Public reporting burden for this form is sstlmaled to average 2.4 hours Per resporee. no burden estimate includes the time for reviewing tnstruudioms, searching exketirg dcta sources, gathering and maimWnirg the needed data, and completing, nwisMM and subm0ting the form.'r You are not required to respond to ttds'col WC*M of h* n w*m unless a valid OMB control number displayed he upper burden um right corner of this form. Send comments regarding the accuracy of the burden estimate art any suggsstkm reducing Information Collections Management, U.S. Depsrbnent of Homeland Security, Federal Envmgency MarapNnent Agency, 500 C Street, S.W., Washington DC 20472, Paperwork Reduction Project (16604034 Submission of this form is required to obtain or retain benefits under the National Flood Insurance Program. This form should be used to request tint the Deparbnent of I km msland Security's Federal Emergency Management Agency (FEMA) remove ■ single structure or legally recorded Parcel of land or portions thereof, described by metes and bounds, esrtilled by a registered Professional engineer or licensed land surveyor, from a designated Special Flood Hazard Area (SFHA), an area that would be Inundated by the flood % having a 1chance of being equaled or exceeded in.any given year (bass flood), via Letter of Map Amendment (LOMAA). It shall not be used for requests submitted by developers, for requests Involving multiple structures or lots, for property In alluvial fan areas or coastal high hazard areas (V zones), or requests Involving the placernwIt of 110. (NOTE: Use MT -1 forms for such requsste� Fill le defined as material from aryl source (Including the subject property) Placed that raises the grade to or above the Base Flood Elevation (BFE). The cannon construction practice of remoybg unsuitable existing material (topsoil) and backfilling with soled structural material is not considered the plecenent of All if the practice does not alter the existing (natural Wads) elevation, which is at or above the BFE Also, fill that Is placed "before the date of the first National Flood Insurance Program (NFIP) map show'na the area M an SFHA s considered natural grade. . r.n— #..,,..;reEnlzjqgMA"statin trot an existing structure or parcel of land that has not been LOMA:elevated by All wand not be inundated by the bass A - This section may be completed by the ProPsrty owner or by the property owners agent. In order to proms your request+ all information on this form mud be completed In its entirety. Incomplete submissions may result in processing delays. 1. Has fill been placed on your property to rales ground that was previously below the BFE? ® No ❑ Yes - If Yes, STOP!! - You must complete the MT -1 application force; visit http:ihvww fema uovlpianlpreveaVfhm/dl mt-1.shtm or call the FEMA Map Assistance Center toil free: (OTT -FEMA MAP) (877-336-2627) 2. Legal description of Property (Lot, Block Subdivision; complete description as it appears in the Deed Is not necessary) and street 8 Y6,��of�Pro�: /73 _T1V6ALC-S S7 A/OR704 AAIDOVe-R MA 3 Are you requesting that the flood zone designation be removed from (check ore): ❑ Your entire legally recorded Property? E] A portion of your legally recorded property? (A certified metes and bounds description and map of the area to be removed, cerdfled by a registered professlonal engineer or licensed land surveyor are required. For the preferred format of metes and bounds descriptlas, Please rater to the MT -EZ Instructions.) A structure on your property? What Is the date of construction? / q q 3 All documents submitted in support of this request are correct to the best of my knowledge. I understand that any false staterent may be I pnmlehabie by Ane or imprisonment under Title 18 of the United States Code, Section 1001. Applicant's Name: ,/} M E= S l7 wL Mailing Address (include Company AAk Ho SvRv�y iNG 453M R cv r M A o i 8 q Signature of Applicant (required) 00 E -mall address: J. A 14 o C° C - D M LAS 7. Nr --r Daytime Telephone No.: Fax No.: 78 — 45`x— 153 6 9'78-Y5y- 1508 We /-2,/-09 DHS - FEMA Form 81-82, SEP 07 MT -EZ Form Page 1 of 3 0 Ei ar r4 to N Cn W b b 41 N W C6 0 W a 9a d BK 7199 PG 89 QUITCLAIM. DEED I, Olivia S. Harding, North Andover, Essex County, Massachusetts for consideration paid in the amount of Five Hundred Thousand and 00/100 ($500,00.00) Dollars grant to Maria L. Guadni, individually with Quitclaim Covenants A certain parcel of land with the buildings therm located in North Andover, Essex County, Massachusetts, situated on the Southerly, side of Forest Street and the Easterly side of Ingalls Street and numbered and shown as Lot 2 on "Plan of Land located in North Andover, MA. Prepared for B & J Builders, Inc., Scale 1° = 40'" dated June 1, 1980, and recorded June 16, 1981 in the North Essex Registry of Deeds as Plan No. 8654, to which plan reference may be had for a more particular description.00 Said premises are conveyed subject to and with the benefit of easements, rights of way and restrictions of record if any. Being the same premises conveyed to the Grantor by Deed of Sainah Rahardja, dated July 30, 2001 and recorded with Essex North District Registry of Deeds on July 31, 2001, in Book 6284, Page 309. Witness my hand and seal this Q�') day of October, 2002. IXIMW nsetts 1Seei Excise Stamps in sum of $ _ 2280.00 affixed and cancelled on this instrument. Essex, SS. COMMONWEALTH OF MASSACHUSETTS OCT' 5102 At11:59 !d 12 , , 2002 Then personally appeared the above named Olivia S. Harding and acknowledged the foregoing instrument to be her free act and deed, before me, 1lnnnn�4� A rnc.�ine l;ft.n s: 07/07/06 Saturday, May 05, 2007 08:05 AM k � L- "AEL ! OF 15 #310 My 094twx *ow *Assets mat pwlhvw at rr 3 1 mmo!"m i - t ASNK7 Saturday, May 05, 2007 08:03 AM Location/ 7J �_ �''' -Al No. Date.40 40RT" TOWN OF NORTH ANDOVER F 9 Certificate of Occupancy $ �'�s'•••° • E<� s�cNus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # �lr �►� 14224 -Building i Inspectof' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING __R, .y.'.',...... .. F k : 241 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 173 .rn6,41.1-5 57-1. 1.2 Assessors Map and Parcel Number: no ()o /aS �.+� 3 - Map Number- Parcel Number ' t� e /f, n d o ve r, 1 t 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RaIttired Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. blood Zone Information: Public ❑ Private ❑ Zone outside blood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record SI\11yAH RAHARI) A t'7-6 1Y)gcL S St t�, ArMdover� Name (Print) Address for Service VJAAAIC-?a r L* Signature J 2.2 Owner of Record: l �7 ATPA r7-1 Na a Print Address for Service: �r Si ngture Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Ipcensed Construction Supervisor: ►� 14. )A Licensed Construction Supervisor: Not Applicable ❑ 2 S� 5 le�/o3 1 H, License Number Address C:X� �D Gi 4- 1 �Si e elephone Expi ratio Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ SAM e A-s -3 . 1 nnh � 1 "- Company Name Registration Number Address V&/04/2,00-2- Expiration ate Signature Telephone MU M O N M r rM �d S N SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) 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 permit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ \-) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ -Specify _ Brief Description of Proposed Work: Convert ey,ls�lnq Screen room on aeaen dec _- 3 5Casor) Green house Qiigind green rQonm 1ZxlZ New gyeenhcusc. isy iS roof SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1. Building Estimated Cost Dollar (Dollar) to be Completed b permit applicant 000, �QF]F ICIAtUSE QNLY, r; r. + Ja) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 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, !; A i Af A H 6h HAP_d A as Owner/Authorized Agent of subject property Hereby authorize N a � l eY �5 oy- % to act on lf, to all matters relative to work authorized by this building permit application. MM. -L - TtAL_\/ZB, Signature of Owner Date SECTION 7b OWN AUTHORIZED AGENT DECLARATION I, kkQMhas Owner/Authorized Agent of subject propert Hereb de lare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and lie �'� N Print ame SiNatAe of Owner A ent Da NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION- THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLED OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the�11 applicant and or landowner from compliance with any applicable requirements. 6,-,,d-1 f APPLICANT 5ai h A Ra hardia PHONE ASSESSORS MAP NUMBER 16�5' LOT NUMBER Q SUBDIVISION LOT NUMBER STREET Gi�6 l�e� STREET NUMBER OFFICIAL USE ONLY i; 014 lmommmommmoommmmmounneommommummummmmmmummonommmmommesses RECOMMENDATIONS OF TOWN AGENTS o0 ............................................................................. Z;( ��'� �� L�. DATE APPROVED '44 14 n ONSERVATION ADMINISTRATOR A DATE REJECTE gL TOWN PLANNER DATE APPROVED DATE REJECTED DATE APPROVED FOOD INS OR -ILETH DATE REJECTED DATE APPROVED /r/// SEP' C X01PECTOR - HEALTH ! DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Y, Ie d I F - LL! Lu J z NOTE: ON OCTOBER 20, 1996, 11 INCHES OF RAIN FELL IN THIS REGION. THIS AMOUNT IS NEARLY TWICE THE 6.4 INCHES FOR A 100 YEAR EVENT IN THIS AREA. THERE WAS NO WATER OBSERVED IN THE BASEMENT, DRIVEWAY OR REAR YARD OF THIS PROPERTY. VERY TRULY YOUR SCOTT L. GILES R.P.L.S. I CERTIFY THAT. THIE OFFSETS SHOWN COMPLY WITH THE ZONING BYLAW OF NORTH ANDOVER WHEN BUILT MORTGAGE PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE:1 "=40' DATE:9/26/96 :12/10/96 Scott L. Giles R. P. L. S. 50 Deer Meadow Road North Andover, Mass. LOT #3 LOT #2 51,273 S.F. PLAN #8654 N. E. R. D. I I I 1 No THIS BUILDING IS NOT IN A FLOOD HAZARD ZONE PER FIRM. MAP 250098 0009 C. OFFSETS SHOWN 'E FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS ,'=OR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. 13072 Town of North Andover' Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM NORTH �ti � 6Y o o41) L 9_ c«n�cw.wnc■ �. In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: WA -S i E-- e j" de:w T 7 qc) B 20,4-owk-; M Facility location I J` 72 SigRddfu're of Affoli`cant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name:M� Location: City hlOr ,�u t7 �- � ti`"► Phone aam a homeowner performing all work myself. ©I am a sole proprietor and have no one working in any capacity F1 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policy # Company name: -T. AAaymr--- " Address—r-�.-=�`t�r.�.�o--) t F� AYE City:DI i Phone #: I Co 7� 2 F5- -39Gi 4.--j Insurance Co.A11W,:;LLc-4 �-AUV-v*-L, 'rize 1z1.4__C1d0o1icv#-,4'T 77; Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the Print name provided above is true and correct. Official use only do not write in this area to be completed by city or town official' []Check If immediate response is required Building Dept Contact person: Phone A FORM WORKMAN'S COMPENSATION ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other ✓iie ioomv�na�uealt�- a� : `iavaac�t«aetla BOARD OF BUILDING REGULATIQNS ' License: CONSTRUCTION SUPERVISOR Number: CS 062883 Birthdate: 10/15/1961 Expires: 10/15/2001 Tr. no: 7737 Restricted To: 00 JAMES H HOTVEDT _ 7 PENNSYLVANIA AVE NEWTON UPPER FALLS, MA Administrator �-\ 7e Vo�nnnanuiea�Ut r�� liaaurclr.�,leliJ HOME IMPROVEMENT CONTRACTOR Registration: 121616 Expiration_ 06/04/2002 Type: Individual JAMES H. HOTVEDT JAMES HOTVEDT G� �o V PENNSYLVANIA AVE ADMINISTRATOR HEa10N MA 72154 F6 ion ALLIED/SUNRISE ENCLOSURES COMPANY PROMS & 78 THORNTON STREET. BOSTON. AAA 02199-1495 VOICEMAX (817)499- 4807 FAX (817) 427-8800 AGREEMENT made as of the day of Two Thousand Between the Seller, Jon Ellertson dba Allied/Sunrise Enclosures Company, and the Buyer(s) Saina Rahardja Address: 173 Ingalls St, North Andover MA 01845 Phone: (978) 725-4843 (978) 557-9170 Home Work Fax PROJECT: Convert/expand existing screened porch on upper level deck to red cedar framed Victoria Greenhouse See drawings and Specifications pages attached Buyer and Seller agree as set forth below: Article 1. Description of Materials See Specifcations page 3 Cost $I11 -Z8,410 [ ] Check if Materials Purchase Order or Worksheet is appended as part of this agreement. Local sales tax $ 5 6 q. 3 D [ x ] Check if Specification Sheet appended. Freight/delivery $ -14 % t. Installation/drawings $ t,g Do Permit $ ( to be reimbursed ) to this agreement Grand total plus estimates as noted $ ;L0, 1 y,©E q a Article 2: Schedule of Payments All of the above materials (plus installation if noted) are to be delivered/completed in a substantial and workmanlike manner according to standard practices for the SUM of Twenty Thousand six hundred fifty..................................................................................................................................And 90 /100 Dollars Payments are to be made: $350. Upon agreement (initiate drawings/ bind agreement/guarantee prices) [ x ] Check here if additional $7,000 deposit to start fabrication process payment stages are specified $ 7,000 Prefabricated materials etc COD on page 3 $ 3,200 Upon commencement of installation (incl. Frt/delivery if applicable) $ 3,100.90 Balance upon completion of installation Final payment shall include all agreed upon reimbursements and reconciliations for extras, if any. Article 3: Acceptance The articles of Agreement constitute the entire agreement between the parties and no oral representations, promises, changes, alterations, or modifications of any of the provisions of this Agreement shall be binding upon the Seller or accepted by the Buyer unless made in writing. The Seller shall not be liable for damages for non-performance of this Agreement when such non-performance is due to causes beyond the control of the Seller, including but not limited to Acts of God, labor difficulties, transportation difficulties, unusual market conditions, wars, civil disruptions, military activities, legislation, regulations, requirements, priorities and orders of any Governments, Federal, state or local, or any agency or persons exercising governmental or judicial authority. Description and Identification of Security Interest: a Security Interest is retained in the goods described in this Agreement and are subject to the Uniform Commercial Code of this State. Buyer acknowledges receiving a separate copy of this agreement and understands the terms and conditions printed herein and agrees to such terms as a part of the Agreement. SIGNED: Seller Jon Ellertson Date: �17i2ltr� place of signing: 173 Ingalls St. N. Andover Article 4: Notice of cancellation Date of transaction: `l 1I/V 00 You may cancel this transaction without any penalty of obligation wrthm 3 business days from the above date. If you cancel, any property traded in, any payments made by you under the Agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the Seller of your cancellation notice, and any security interest arising out of the transaction will be canceled. If you cancel, you must make available to the Seller at your residence in substantially as good condition as when received, any goods delivered to you under this agreement; or you may, if you wish, comply with the instructions of the Seller 6172,i-dj2 TERMS AND CONDITIONS FOR PLACING AN ORDER page 2 of 7 pages 50% deposit on all standard orders. Balance is due a min nium of 5 working days before the shipment leaves the factory. For this order, that ship date is estimated to be : / / If the Buyer does not make this final payment schedule, the shipment will be sent COD with a carriers' COD charge added to the freight bill. Set by the carrier, these COD handling fees may add 3-4% to the unpaid balance. Custom orders: To place an order for a custom design, based on drawings sent to the factory for pricing and engineering verification, a 75% deposit is required. Balance is payable as above. Custom orders normally require additional lead time beyond standard orders. Freight: Seller shall inform the Buyer of the delivery schedule with a phone call once the shipment leaves the factory. Once the carrier has logged the freight charges into their tracking system, the amount of the bill will be known so that a check can be made out to the carrier or Seller. The Buyer's check must be available at delivery time for receipt by driver. Change orders: Once an order for specialized materials is made, any change in specifications including location of doors, windows, etc. will result in extra charges and delays in delivery dates. Cancellation: The specialized materials described 'in this agreement are to the Buyer's particular specifications; thus, once fabrication has commenced, the order cannot be canceled without incurring a fee. Cancellation prior to commencement of fabrication may yield a partial refund to the Buyer, not to exceed 50% of the original deposit, at the discretion of the Seller. Once fabricated, the parts must be paid for in full. Permits and fees: The Buyer is responsible for paying for all local permits and fees. If the Seller has agreed to coordinate filing for the permit, the Buyer shall reimburse the Seller for any permits, including surveys and or engineering documents sometimes required by local officials, as long as the Buyer has authorized such expense. Buyer has the option of securing his/her own permits and waiving the Seller's permit processing fee of $350. which includes scaled drawings. (Fee for drawings only: $150.) Please Indicate no Has Responsibility: [ ] Buyer(s) will file for permits. [ ] Seller is given responsibility to file for permits. Checked and initialed by buyer. A A R R R R A R R R R A R R* A R R R A A R A* A A A R R A A R A A W* R A R A R R R R R R A Payment Schedule And Record: —R- Amount Date Check # 1. Deposit to place order/file for permits: $ '-S-D 2. Factory release payment: $ 3: Freightpayment or reimbursement $ 4. Start construction (if by Seller): $ 5. Progress payment #1 $ 6. Progress payment #2 $ 7._ Progress pavrrrent #3 $ 8. Substantial completion of project. Write "Punch list": $ 9. Punch list completed, site cleaned. Write "Evaluation". $ Total of Payments $ 20, (oS p, q O Manufacturers's warranty statements and related paperwork will be given to the Buyer and final photo documentation done upon completion. Installers' 5 year workmanship warranty starts upon completion with final payment in full. Owner responsible to follow maintenance schedule outlined in "Protecting your enclosure" which is part of the Limited Warranty Certificate. Evaluation: Seller requests a written evaluation ofthe project from the Buyer to reflect upon both the planning and execution of the project as well as the final finished project. Buyer extends permission to the Seller to use at his discretion the photographic and written evaluation of the project in marketing and/or documentation efforts. Page 3 of 4 Specifications Rahardja Greenhouse (conversion of existing screen room). 173 Ingalls Street, N. Andover, MA Convert 12 x 12 screen room to 12 x 15' 5 1/2" 3 season (sun tempered) greenhouse by removing the lower '/i of the existing roof, adding 3' x 6' to the remaining solid roof. Replace the gable ends, front wall and the front'/z of the roof area with natural finish Victoria design greenhouse (western red cedar and high performance glass components). All roof glass, including 2 retrofitted skylights: Heat Mirror triple glazed units (SC 75 grade) 1" overall tempered over tempered units. ( R-4); extruded aluminum glazing caps. All vertical wall glass, including 2 screened casement windows by Landmark and 1 Andersen Frenchwood gliding patio door (white vinyl exteriors): Low E argon gas filled units. Fixed units shall be 1" overall; 34 x 76" size units shall be tempered as well as 2 small fixed units under the casement windows. Roof. support existing roof, cut back rafters to permit installation of 3 ply LVL (9 14" depth) as a transverse beam supported at each end by dimensional posts (hem/fir). Extension of existing 12' roof to the new 15'-5 '/2" width shall be with standard framing to match existing framing. Weave new section of tab shingles into existing shingled roof. R-19 insulation in floor and solid framed ceiling. Ceiling finish and rear wall finish: GWB taped and ready for painting by owner. New greenhouse rafters for 34 x 76" Heat Mirror glazing shall be western red cedar 4x4. Additional red cedar 4x4 posts/endwall headers; 2x4 red cedar top and bottom plate for 4x4 cedar frame. Seasonal exhaust fan: TC1000 axial greenhouse fan by Tamarack Technologies, W. Wareham, MA, with line voltage thermostatic controller. Installation by subcontract electrician. Floor: masonry file over cement board underlayment. (Owner supplies tile) Special materials including Victoria design greenhouse : $117850.90 Other materials required for site work (insulation, Boise -Cascade LVL engineered beam) Drawings and permit preparation Labor Electrical Permit: fee shall be reimbursed by Owner $ 1,250 $ 350. $6,550. $650 (est) Total installed price: $20,654.90 Payable in 4 payments: 1. $350 upon acceptance --prepare permit application; Plus reimburse for permit fee 2. $7, 000. Deposit for special order materials 3.$71000 Upon commencement of work/delivery of materials 4.$37200 Upon completion of greenhouse framing 5. $37100.90 Upon completion of all work/broom clean site.. Limited 1 year warranty on workmanship; Victoria glazing system warranted leakfree for 5 years. Rahardia Greenhouse. 1.73 Ingalls St, N. Andover, MA Floor plan and elevations. Convert screen room to 3 season greenhouse on existing deck. 12 13.5 west elevation South elevation east elevation 12'-2" . — 1 �' . 15' 5 '/Z " -- 12'-2" 2 �eRTH' Iz. Floor plan Scale: 3/16" =1'-Q" Hatch line shows LVL 3 ply 9 1/4" in roof Allied/Sunrise Enclosures Company 76 Thornton Street Boston, MA 02119-1415 Voicemail (617) 499.4807 Fax (617) 427-8800 To Conservation Commission, North Andover, MA From Jon Ellertson, Owner's agent RE: 173 Ingalls permit application August 11, 2000 Regarding the permit application to remodel the existing screened rear porch at 173 Ingalls St. Please note for the record that there will be no new excavation since the existing deck and porch are already on concrete piers. No additional piers are indicated in the plan. If you have any question, please contact me at (617) 499-4807 cc: James Hotvedt, Design/Build Sainah Rahardja AUTHORIZED DEALER Creative Structures (cedar, mahogany and oak framed straight cave and conservatories); 3 and 4 Season convertible "SunBreeze ' garden rooms by Artistic Enclosures; Victoria SunPorch and SunBay--for the Look of New England; Skytech aluminum curved and straight cave solariums; Heat Mirror and SuperGlass--superior performance for new or replacement work; Awnings; Western Red Cedar trellis, arbors, and sundecks. Residential and commercial. A Spring Flower Show Exhibitor since 1985. Founder: Charity Begins at Home --a network of vendors / tradespeople helping to generate funds for your favorite charity. MA licensed builder # 0429631 registered remodeler #115902. Fully insured House floor plan Residence at 173 Ingalls, North Andover, MA Ltvtn9 Room -1 S LeW 211 Leve, scale: 1/8" = 1'-0" Family Room Ptrn(n 9 K�-�chen �hroern ry Roam \ SL.tDE�' D� 56D Room i_tntr) 0 bafh Notes: Footprint of house: 28 x 45. Basement: unfinished plus 2 car garage Attic: Unfinished storage with access from 2' floor Prepared by Jon Ellertson from field measurements made August 10, 2000 and submitted by request to Susan Ford riper) REA2 ST4 t Rs Tb Sc:n�ck Screenzp o ,fl ��f�CvlhcuSt a 01Z E Pot�+ch f �I STv < ,R MdST�R a Olt a�pCccnc\ fE' 56D Room i_tntr) 0 bafh Notes: Footprint of house: 28 x 45. Basement: unfinished plus 2 car garage Attic: Unfinished storage with access from 2' floor Prepared by Jon Ellertson from field measurements made August 10, 2000 and submitted by request to Susan Ford I C E o •a� c C •- O y• C V V ' •dam r C m C t C v) ji CS a Z iA o c `mc E y � o m3� cn -� -COD ! C vi � �► c W Cc Em W � m o cm =CJ 4DL= c oc Z oa A� ccil —0 0 V: Coo cm. CL c �Ie/� m C m 3 f— r Hood o ku c �., c� »- H .y SOC Z � m •y O C.3 o U m CO g CO2CL �� OS .! y GD y E O CL co CDC Q CO)CL 0 0 Q CO2 O !c r. d CIO I�mw L O V CD C. CA Q CD c, c Q ,c O m m f+ O Q CL cmQ CIOC 'O O co Z Z C. CA C 0 U) U) Irw w W U) � ° x a x z ^per o w V>)-v aai V) ca ro- 'd p w -S p cL C C U Cda G x w toa 0 a G x w W O w u chi G ii p E� moo 0 c�: w w w c ? CO ° V)cn C O E o •a� c C •- O y• C V V ' •dam r C m C t C v) ji CS a Z iA o c `mc E y � o m3� cn -� -COD ! C vi � �► c W Cc Em W � m o cm =CJ 4DL= c oc Z oa A� ccil —0 0 V: Coo cm. CL c �Ie/� m C m 3 f— r Hood o ku c �., c� »- H .y SOC Z � m •y O C.3 o U m CO g CO2CL �� OS .! y GD y E O CL co CDC Q CO)CL 0 0 Q CO2 O !c r. d CIO I�mw L O V CD C. CA Q CD c, c Q ,c O m m f+ O Q CL cmQ CIOC 'O O co Z Z C. CA C 0 U) U) Irw w W U) NATIONAL GRANGE MUTUAL INSURANCE CO. FLOOD INSURANCE PROCESSING CENTER P.O. BOX 7777 ROCKVILLE, MD 20849-7777 (800) 368-7720 11/04/1999 NORTH ANDOVER INS AGENCY INC 9 WAVERLY ROAD ` NORTH ANDOVER, MA 01845 RE: Flood Application for: SAINAH RAHARDJA POL#1478802344 WYO Company Name: NATIONAL GRANGE MUTUAL INS CO. Dear Agent: To assist you in the placement of this business we need the following information to develop rates: t ) A signed Elevation Certificate completed in full. (XX) ORIGINAL photographs of BOTH THE FRONT AND BACK of the building or, if builders risk, the blueprints of the building. (XX) A copy of the variance.that should have been issued by the community permit official prior to construction. If the permit �° official or insured indicates that no variance was issued, please provide a written statement to that effect. t ) Certified letter verifying that any such enclosures are de- signed/built with break -away walls. The insured's check is enclosed. Full premium is to be submitted - when a rate has been developed. NO PREMIUM IS TO ACCOMPANY THE SUBMISSION. Rates will follow under separate cover. t ) Please complete the required information on the attached Part 2 of the application form. THIS INFORMATION IS CONSIDERED ESSENTIAL for underwriting and will assist in developing the rates for this risk. _ (XX) Elevation Certificate invalid,it does not show the Zone. .The policy will be effective after the necessary underwriting information has been received, a rate developed and the full premium received. TA) :t CI Ct ot � , dna f 8RLT2