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HomeMy WebLinkAboutMiscellaneous - 175 OLYMPIC LANE 4/30/2018 (2)/ \ N_ O � J w �_ Q o m I o � Date. J �'114 -,J�. ....... NORTH 11 M TOWN .OF NORTH ANDOVER"/ • PERMIT FOR GAS INSTALLATION Io �N This certifies that . i�. -T—/. . .� ep. . /-/ . . has permission for gas installation SU U e. in the buildings of/ . .�7. (� 41 -v 5 ........................... ad, .77.S_ C). L A -4'-r— Nrth Andover, Mass. Fee..Lic. No GAS INSPECTOR Check4t:Vj) 7052 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations L Date J2-1 Permit # Amount $ Owner's Name�� New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type) Check one: Certificate Installing Company Name . ,-/�1?�d'yl �Ocf— i� Corp. Address �a 15,0 Partner. us�mess TTelephone q Z F7,, k2a e T -2-0 Finn/Co. Name of Licensed Plumber or Gas Fitter t) �j lJ�p,��yj evw —� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13— No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy [a Other type of indemnity 1:1 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent El ncrcoy cenity that an or ine aemns ana mrormation 1 best of my knowledge and that all plumbing work and i compliance with all pertinent provisions of the Mas JAPPROVED (OFFICE USE ONLY) Signature of I Plumber RGas Fitter Master 0 Journeyman (or entered) in above application are true and accurate to the °ormed under Permit Issu,Vd for this application will be in s Code anhapter 14*f the GeneA Laws. se&Tlumber Or Gaff�s Fitter 4 I tcense NUrnffer � W U F q z C a O w Fw- GC7 w Q x v� aH 7 x Q F Qz x" W C w C W W F Q w c. Q a > M z O U 0 v, &n m o x w 3 a U °a > A a H o SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR - 8.TH. FLOOR (Print or type) Check one: Certificate Installing Company Name . ,-/�1?�d'yl �Ocf— i� Corp. Address �a 15,0 Partner. us�mess TTelephone q Z F7,, k2a e T -2-0 Finn/Co. Name of Licensed Plumber or Gas Fitter t) �j lJ�p,��yj evw —� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13— No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy [a Other type of indemnity 1:1 Bond 13 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent El ncrcoy cenity that an or ine aemns ana mrormation 1 best of my knowledge and that all plumbing work and i compliance with all pertinent provisions of the Mas JAPPROVED (OFFICE USE ONLY) Signature of I Plumber RGas Fitter Master 0 Journeyman (or entered) in above application are true and accurate to the °ormed under Permit Issu,Vd for this application will be in s Code anhapter 14*f the GeneA Laws. se&Tlumber Or Gaff�s Fitter 4 I tcense NUrnffer 10 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA -02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a.sole proprietor or partner- listed on the attached sheet. $ 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-❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -J -rfl — ; aLzUS< ii R) :u3 out me secnon below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone #: 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. Cita / own Clerk 6. Other 4. Eiectrical Inspector 5. Plumbing Inspector Contact Person: Phone #: 1 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 returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonweal) . of Massachusetts DTartinent of Industrial Accidents Q Lice of Investiptions 600 Washirigton. Street Baoston, MA 0.2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax # 617-72.7-7749 Revised 5 -26 -OS NA�vv.mass.zov/dia Location �L `�W1,i7 1C LN,_ No. Date�� } • i ss�+cauSE� Check # %-9 15695 TOWN OF NORTH ANDOVER Certificate of Occupancy $ U Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ _It 0 /v' `l J�� J Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT OR BUILDING PERMIT NUMBER: / SIGNATURE: of I SECTION 1- SITE INFORMATION I ONE OR TWO DATE ISSUED: 17— Date 7` Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number: lD� d 3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R Wired Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 alms- I IVP1 L - r.KurJ KI I V Wf'4A-KNn1r/AU IMAULED AGENT 2.1 Owner of Record IVA- xy g=' VMS 2j'' o l- y/w / c o vF Name (Print) Address for Service: Telephone 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ "ID &VIP 0,hSTI C 0 E /FFG +- SSG. Licensed Construction Supervisor: 1q License Number ® �` s t�TTD /� S ": Af r �.�1% D 1T�/�� f 17 Address=,,, R I Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor ; Company Name 4, D b LL 7-7!o Ill S T r d 6 V 0 Iy U E!?, 1-1 e,4A—.. T Not Applicable ❑ Registr— ati Number �2 !/`t /0 z Expiration Date T�q M M v z z M 0 mn M< G) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 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 permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Jterations(s) 0 7 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b ertnit applicant i v tai s'`i3IIA'T)SE�ON a��iv' �t1�x �"'�t: t/`it �'h�t5 yL f�,yj�t��'i r xazr �.. Q u i , ....gi g =.a3 . ; '. ' r a+� r :.��. f 4r tV m<: 1. Buildingtas3 /0,700Multiplier (a) Building Permit Fee 2 Electrical (b) Estimated Total.Cost of Construction 3 Plumbing Building Permit fee (a) X tbl -- D 4 Mechanical (HVAC)'" 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZA ION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION LL 1, AV J� /� S T I /?' as Owner uthor ezi d Agen of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the hest of my knowledge and belief Print _ A Si ature of Owmer/A ent Date NO. OF STORIES SIZE i BASEMENT OR SLAB RD SIZE OF FI.00R T 1vIBERS 1 S7 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOO"TING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE S (�r G //1" lift". linard of Building Regulations and Standards 1I HOME IMPROVEMENT CONTRACTOR Registration: 104.569 Expiration: 7114!02 Type: PRIVATE CORPORATION DAVID CASTRICONE ROOFING, S Ma& &astricone 7 Hillside Rood �....L l✓ Boxford. MA 0192' —_ Adminixlralur AGAR—WL CERTIFICATE OF LIABILITY INSURANCE 1 �a%z9�zo0i PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INTERNET TN3t1;WC9 AG]SN'Cy HOLDER. T1418 CERTIFICATE DOES NOT AMEND, EXTEND OR 522 CHIClf)BRil®G ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 140ATK ANDOVER, MA 01845 I INSURERS AFFORDING COVERAGE INSURED DAVID CASTRICON3 ROOFING ANC SIDING INC. 200SUTTON STREET, RVITZ 226 NORTH ANDOVER MA 01845— fl^v9• R A C: GC INSLIRGRA: AMLLA INSURER B: AltBZLLA PROTECTION INSURER C: ROYAL SUN AGLIANC6 INSURER D: INOURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOk THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHRR DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION$ OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE POLICY NUMBER POLICY IPF90TIVE POLICY EXP) N LIMITS A WENERALLtABILITY COMMERCIAL GENER�AL LIABILITY 19500012710 06/06/2001 � Ofi/46/2002 EAC14OCCURRENCE 3 1 000,000 CLAIMS MACE l u1""LL`UR I -FIRE DAMAGE (Any onefiro s 50�OOp V MED © CAP Ignyone, peroon S 5,000 PERSONAL & ADV INJURY 1 11000,000 Ijl GENERALAOOREDATE 1 1,000,000 GENL AGgREQATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AOG S 1,000,000 POLICY PRO LOC AUTOMOUIL,E LIABILITY 1 COMBINED SINGLE LIMIT i ANY AUTO (Ea emWent) H L❑ f" ALL OWNED AUTOS 1144505400001 08/01/2001 00/01/2002 BODILY INJURY a 250,000 SCHCOULSO AUTOS I IPOI petien) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Pitaftidifi) is 500,000 PROPERTY DAMAGE (Petaceld.nel �3 100,000 j GARAGE LIABILITY AUTO ONLY EA ACCIDENT 1 ANY AUTO OTHER THAN EA ACC s AUTO ONLY: AGG 3 EXCESS L"ILITY I EACH OCCURRENCE AGGREGATE 6 OCCUR CLAIMS MADE 4 i 060UCTIBLE RETENTION & S WORKERS COMP4NSATION AND Li I EMPLOYERS' LIA5ILITY TORY LIMrrr C i i91Sy79A01 09/23/2001 09/23/2002 E.L. EACH ACCIDENT s 100,000 E.L. DISEASE - EAENPLOYE $ 500,000 El. DISEASE - POLICYLIMIT y 100,000 OTHER DESCRPTtON Of OPCIVITIONSILOCAT70N4tVF;KIGLESiEXCLUSIONS ADDED BY ENDORIEMENTISPECIAL PROVISIONS SHOULD ANY OF THE AEQVE DE96RIDE0 POLICIES BE CANCELLRD DEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITT' 7 1`4=' 10 THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT PAILURE TO DO SO SHALL IMPOSE NO09LIOATION OR UABILRY OF ANY KIND Ll" THE INSURER, ITSAOENTS OR AUTHQRl2E0 1988 C/) m m C/) 0 m S- d CDo MZ y C.O n� � � O CL y >to 0 CD O p CD O d CD Sr CD 0 CD 00 00 C CD y CL v yCD —• o co CODC S v CO) O 'v Z CD O CD O CCD O so o Q N d0Sm .0 CO) CL m C7 cm 3 m Z J fl N 0.0 = Ndi m y T a -•a ME�pCDh C y N =m m 2 O C Im y�0 • m S. 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