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HomeMy WebLinkAboutMiscellaneous - 183 FRENCH FARM ROAD 4/30/2018 (2)N 8990 HOR7q o�,.° 3r •`_? " •' OL t4c� D ,SSACMUSE� Date .6--TO . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .4v\.. t� �".� t e-"7 has permission to performc,c.ovrve... . E�.�5�"^^ ......... . L plumbing in the buildings of �•Y`^� ............................. at .. . .....:' .. V�... "r .............. . North Andover, Mass. Fee.'` ,.5.a. Lic. NoZ! . � _ PLUM BII INSPECTOR Check # , 3 Af 2�a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date: Permit# Building Location. 07� /"fir-� Owners Name�— /!�l Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy. X Other tvae of indern ifi, f-1 r--1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 742 m the General Laws By Type of License: Title lumber SI nature o�ce mber City/Town d.11 ivlaster APPROVED OFFICE USE ONLY ❑Journeyman License Number:R. a�-%e DEDICATED z Z SYSTEMS Y Z 0 LnD Z a w Z Y ¢ z z a u ¢ w C 0 Z o: oc 0 LU R w D Q Z ¢ h Y Ln Ln OJ — ~ r¢i v, �w Q Y 2 w v 3 O w 0 ° 0 "' vZ_i x a. 0 x Z Q �'- 3 � Y a z x "' w w o: x oi! O Q m 3 w Q Q a m m H h 0 a i > > 0 x 0 o o LL x 3 g a: in Z ¢ Q Q to w a H -SUB BSMT. o a c9 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR Installing Company Name: Check One Only Certificate # Address• bbd City/Town: /�r.� State: ❑ Corporation '7 Business Tel: / r- S =�%%� Fax: � ❑ Partnership �— ,Firm/Company Name of licensed Plumber: --jej 4we_/ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy. X Other tvae of indern ifi, f-1 r--1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 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 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 742 m the General Laws By Type of License: Title lumber SI nature o�ce mber City/Town d.11 ivlaster APPROVED OFFICE USE ONLY ❑Journeyman License Number:R. a�-%e Date ... ....,1....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 9ILeh lo -n This certifies that ....................................�V. .............................. has permission to perform ..7...../.' G-�!1..................................... wiring in the buildingoff j.�? Cj'/t'f z .......... ................................................................... / at �3 7 /IL�1 �......�..n... orth Andover, Mass. ...... ., Fee ...?..1 .............. Lic. No.. ............ .....................PRi*I *L ....iLEfoR _ Check # ! �_ 0 v elmmonwea& o f Mailac"M Official Use Only eL padEtnea.t o1 _7im Jemicei Permit No. Occupancy and Fee Checked i BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR TION) Date: r City or Town of: /1/,.�h ; r'' To the Inspector of Wires: By this application the undersigned givesnotice of his or her intention to perform the/electrical work described below. Location (Street & Number) / g 3 en/- a<i l a�'i►') ia��.G Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Le No � (Check Appropriate Box) Purpose of Building rim Utility Authorization No. 11 Existing Service 9-00 Amps 1)0 1.oZ40 Volts Overhead ❑ Undgrd ❑ No. of Meters _L New Service .Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Cmmnletinn nfthe fnllnwina tnhle — ho -;-d h„ iL. r„ ,..,,.. m: No. of Recessed Luminaires 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- ❑ rnd. grnd. o. of Emergency-Uighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: I Number """' Tons """"'""""""" KW """""""""""" No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Key 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 E uivalent OTHER: 9921 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectr'cal Work: Q0X� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties ofperjury, that the informationon this application is true and complete. FIRM NAME: /pliTD'7�, LIC. NO.: .9032,r -,A Licensee 11"Ie% _4 C Signature1111�11r LIC. NO.: ,g (Ifapplicable, enter "exempt" in the liKense number line.) Bus. Tel.No.• Address: 12 9 G� , %Y—�S& Zin �Ma 0Z/.�-C3 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 Signature Telephone No. PERMIT FEE: $ �� Q fl- 1 4 M Y // Address 2- G-e� City/State/Zip: S)4oe , 47)9x- OV(,d Phone #: G/ 7 12 ix<l Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I eptployees (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. employees and have workers' [No workers' comp. insurance comp. insurance.$ 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152; § 1(4), and we have no 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. E] Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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. 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. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.' , Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the.legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,.§25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tet. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax # 617-727-7749 Revised 11-22-06 www.mass.gov/dia Date�� 1 TOWN F NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. /.� .4/"... /!`? ............. . has permission to perform ....�............... . plumbing in the buildings of.c. r-. ►. .,-r ................... at ...1. 3 .. r.A "..% , North Andover, Mass. Fee. 7....Lic. No.]. ....... Check # ('� / I 7561 q MASSACHUSETTS UNIFORMAPPLICATION FOR PERMIT TO DO PLUMBING (Print or Type)li/O . Mass. Date ��2C012 Permit # Building Location /a3 Owner's Name �� Type of Occupancy 944 New ❑ Renovation Eir Replacement ❑ Plans Submitted: Yes ❑ No ❑ 19 installing Business FIXTURES B . P . # SF.WF.R# cWpTrr4 Check one: ^✓�— , ❑ Corporation 19 3to 7!P ❑ Partnership ❑Firm/Co. Name of Licensed Plumber Certificate # INSURANCE COVE . I have a current H ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Les, please "Athe coverage by checking the appropriate box A liability insurance policy Other type of indemnity El Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have su ed (or enter d) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations peri ed under ermit issued for this application will be i mpliance with all pertinent provisions of the Massachusetts State Plumbing de pter 14 th era[ By Title signaore< Licensed Plumber City/Town Type of License: Master Journeyman ❑ APPROVED OFFICE USE ONLY) License Number / :9-2ffa to Z Y Q N N N O z !- W Sa P N O Z Q fL cc _ ~ Z O Z to a xl JJ J N W W N N== F Ui W Ncc Y Q N U. Z �. Z E rI [t z W o 0 � N Q W N Q Q = o< a. 0 Z � _a a< 0 1J rT4 W F- S U ~ Q= W. � _ O n. Z S J Y N a. O = J Q W � ..r W Y t) S4 N > a',¢ i. O x N N Q Q i- 0 z <�J o v� < ? x x rt W t- Q C , : J li m W o o J 3 -. t- v� u, c� n Q 3r C: m U. Q C SUB-BSMT. I BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR f1 Check one: ^✓�— , ❑ Corporation 19 3to 7!P ❑ Partnership ❑Firm/Co. Name of Licensed Plumber Certificate # INSURANCE COVE . I have a current H ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Les, please "Athe coverage by checking the appropriate box A liability insurance policy Other type of indemnity El Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have su ed (or enter d) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations peri ed under ermit issued for this application will be i mpliance with all pertinent provisions of the Massachusetts State Plumbing de pter 14 th era[ By Title signaore< Licensed Plumber City/Town Type of License: Master Journeyman ❑ APPROVED OFFICE USE ONLY) License Number / :9-2ffa 0 m m N T m 0 0 m N N i N V m n -a 0 z N O 'fl O C m � m a � z O � ' O 0 0 r C z T m 0 0 m N N i N V m n -a 0 z N Date ...../0 -. ..Z. .5... -e. 7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. h%z%,iU........... J. C /,!`t%1 �t�!� ................... has permission to perform !��%� R/`�o:12" .................... .... .... ............................... wiring in the building of ............. T ..................................................................... n at .....�..3.!i1C�/lam{' .... ! `.6 ............. North Andover, Mass. .................. Fee.. �. - 7 ".;,': �Lic y?...c' e' ......,...< ......... ............��..... . ELECTRICAL INSPECTOR Check # 774 SD -N Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. i` Occupancy and Fee Checked :ev. 1/071 nPa„P �i�nU� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 CMR 12 00 WORK (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: 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) Owner or Tenant ,%� I"e, r A Telephone No.6 Owner's Address /�3 �O1 ,/ Is this permit in conjunction with a building permit? Yes E;—No ❑ (Check Appropriate Boa) Purpose of Building b I , c Utility Authorization No. Existing Service -,,,o Amps iio 1"4, --Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑-- No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: /cJ r aerau iI aesirea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:i-d � .` Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:/g l� e -,i z.aemloq rr LIC. NO.: X-. ? y 0 -`,r - Licensee: -1%�'vo"V—'Pe r. "..T .07 Signature�� LIC. NO.: (If applicable, enter "exempt" in the license' number line.) : ' ?Y AJ - Address: Bus. Tel. No.:-docp-lp Alt. Tel. No.: �19,I -oP 90 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. o Sre� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required g law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ �r j1 nit ,r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 C-1 www mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual); Address: o? j r -Jf 74--, City/State/Zip: Phone #:. 9) jr? iOA cA f Are you an employer? Check the appropriate box: T ecti 1. ❑ I am a employer with 4. ❑ I am a general contractor and I gmployees (full and/or part-time).* have hired the sub -contractors 2. I am.a.sole proprietor or partner- listed on the attached sheet. t . ship and have no employees These sub -contractors have working for mei' any capacity, workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work offlceis have exercised their right of exemption per MOL myself. [No•workers' comp, c, 1.52, § I (4),'and we have no insurance required.] t employees. [No workers' comp. insurance required_] ' *Any applicant that checks bore # I must also fill out th belh Type of project (required): 6. ❑ New construction 7. F-1Remodeling 8. ❑ Demoiition 9. ❑ Building addition 10.❑.Electrical repairs or additions 11.(] Plumbing repairs or additions 12.❑ Roof repairs 1.3.[] Other t e s on ow s owing their workers compensation policy information. homeowners who submit this affidavit indicating they are doing all work and then ham outside eontmctors must submit a new affidavit indicating such. ;Contractors that check this box mustattached an additional sheashowirtg the name of the sub -contractors and their workers' comp. policy information. 1 am..an employer that is.providing:workers' campensatwn insurance for my entplOyeeL- Below is the pOliey and job site information. Insurance Company Name: ' Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy Dumber 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 $4500.00 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 againstthe.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 ofperjury that the information provided above is true and correct �r 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, 925C(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 Conrad for the performance of public work until acceptable evidence of compliance with the insurance Tequirements 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), addrms(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/lieense 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 "ail 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. Anew 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 fo complete this affidavit The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia x ommonwealth of Massachusetts 1 !I Iici,J t t 1111) Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occl.lpancy and Fce C hcckcd APPLICIwi-k to II` ATIONFORrtIcniled II`I PERMIT TO ll lccol-darce mth (lie`PERFORMELECTRICAL WORK , PLE. INE PRL\ T l.\ INK OR TYPE. ILL 1.\ Fc )R.I1. I T1OX,, Date:— City or Town of —� A-5-`� `" -^ e"- -,xz /� r To Idle h),Y11(!c'10t' 0.1 [i'i) -rY.- BY lllis :Ipplication the unJersl�nvJ ,Ives nuhCv (it, his ur hvr intention to hcrli;rm the Clectrical work de5crihed hvlow. Location (Street & Number) ,�e z (caner or Tenant �;�� /� / Telephone No. Owner's Address /d-`3 Is this permit in conjunction with a building permit? Yes ❑-- No ❑ (Check Appropriate Box) Purpose of Building ,,,,�G i Utility Authorization No. Existing Service O G ;\naps f% /j,) 6 Volts Overhead ❑ Und rd g ❑ No. of Meters � i I t 01 i 5 N New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of 'Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical work: r N --9 No. of Recessed Luminaires , .... ,..•1....1,,;,11­­;n11V No. of Ceil.-Susp. (Paddle) Fans l.l' Ih.111- i.! tete 1110 l:iS a•Y-X 1,1 1. No, of Total Transformers KVA No. of Luminaire Outlets No. of Hot'Tubs Swimrrain Pon- above ❑ In- g Generators KVA ❑ u. o mergency Lighting No. of L!aminaires �rnd. frad. 13attcry Units No. of Receptacle Outlets No. of Oil Burners °FIRE ALARMS rNo. of Zones No. of Switches No. of Gas Burners 1 No. of Detection and t Initiating Devices No. of Ranges No. of Air Gond. otaTons l No. of Alerting Devices No, of Waste Disposers Heat Pump :Number Tons KW No. of Self -Contained ('otals: DetectioniAlerting Devices No. of Dishwashers Space/Area Heating KW Local vlunicipal Connection ether No, of Dryers Heating Appliances KW' Security ti stems: No. Devices Equivalent No. of water KW No. o No• of of or Heaters —_Signs Ballasts Data wiring: No. of Devices or Equivalent No. Hydrmn:assaoe Bathoibs No, of Motors Total HP f clecommunications wiring: - n -r• u c o. tio, of Devices or Etuiv aleaat F.tilirli.dt6 ,It, rii �,., i'Cr/. ..,',..P ill; rl"L.l;`l m:►trd �;duv of Electrir.rl `,4' Irk: (Afic), required by municipal policy.) 44oik to start: In:•pection; to be requested in accordance with 41EC: Rllll 10. and upon Complvtiun. t,\.SU IANCE 0A I RAGE: l..ulcss waived by the ut�nvr. no 1:emilt tux the l:erturnclncc 1;1 ,dcetrical '.vurk lnay i.:_ue ui;ik: 'lit: llculsee 171:%: Ies r coo ,r il;lbliltb In"IIf;It1P_ Ill�llldlll!' "C,llll}'letcd 1%I)eraU,lll Cilbcra'fl'':1' !l'; ' UI".I;Illtl;ll �glll�.11t'!Il. I' r - I'l.�I':I''::Ilae tc IIIc- r(_nnit 1:'.1;111' ultl,.e. ILC �� 1`,t� i'•,,i t.A; t iL .,.ly//, .',i<.�r_Y Ir. ,rl/!.1' ,'t!it)r',-l:!rrr,•. td Il(•'rr - . i / •.I.JTt', '.1'%J '1C'. !I7lh'!'/.!'.l?!J Y1.5 7Jl.':r.'J .. +. •�! q' a..9dress:--'lug. T•cl. ! -- _ >... >-- ---' eellflty ' rc:ll !_ :nll';teli'.r I.icun ,, rc.µur� i 1U1 iIJJ ',+l.l I• i ----- t.It. FA. I II,LIiC,li,lc. ,;:,ter .ill. lic,.n.,e nrnllLvr berg: '11 ti Ff�'S INSU !2A \:(-F '-b.+.IVR: t!;..' ora ...,1 the v_µlireJ by !:uw. 13y Iny ,'n;lhuc L'cl .a. I hcr,_hy '.r:libr thi: rCqui!tnl�;lt. I cm Ih:)'_heck 1;nc} [] ..;s,rlvr ❑ 1.:; ;:�r':r .P2,.c, t)wner,'Agrent 6k V✓o_d G p� r�d �fz- q-z�-oC. ��- 0 0 J Lrd I Date.j , /O.�.............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......d.:'±. .... t 4-p .............................................. las--rr t 1/"� has permission to perform .............................� ............................ .................. wiring in the building of ... ��.....r'?'�4�' ........ � r°7 1-4 .............................. at .... v�7h..?....q.e �! ........... ,North Andover, Mass. Feej—s .... Lic. No...........X02 ?�iS` 14 /4 .................................................................. / ELECTRICAL INSPECTOR Check # A 6560 .A V Commonwealth of Massachusetts trrei•11 I ,e 1111, t Department of Fire Services 1> "'i` xt Occupancy anis Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. y 051 ,le,t9e blank) r APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All '.9in•k to he perfomled in ,tectn'tlance \5ith the \1;u:Uhu.e1tS 1' WI—ic,tl Cotle t\If.C). i'' L'\IR 12.00 I'LL ISE PRLN T l.V I.1 K OR TYPE, ILL l.\ FOR.1 t I TION) Date:,,��, _� `� Citv or Town of: To 1111' /rt.9L eC'Inr 13y this ;application the undersigned gives notice of his ur her intention to perti>rn1 the elech-irtl 95ork descrihed below. Location (Street & Number) ,eV,3 (honer or Tenant ,L � xl� c, ` 7 _ Telephone No. Owner's address /g? Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building G —J,, Utility Authorization No. Existing Service O o Amps /tee la.e G Volts Overhead ❑ 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:�/ f,��f , �, w,��,E_, C Con! .:U.", 111 Ill EK: .laeirh,i,lt6[1,:rtu�:A,1,i;i,! Irs,i'(d. •.r,i.i'rrluilcJGt Fntimated Value of Electrical Work: (Gk hen required by municipal policy.) 1kork to start: In:,pcctions to be requested in accordance with EIEC Rt11C 10. and upon ComPICtion. INSLRANCE COVERAGE: L•nless wakcd by the o9vner. no permit Cor the perlornumeC OfeleO•ical work may i,AIC tulle,: Ihr licensee jlro9 ides proof of liahility incur dice includim-, ",.,onlPletCd operation” c �aera�C or its >.uh,tanti;tl equivalent. i h nder,i,.11cd ce'rrifiet that'.uch co9cra^e in IurcC. :111d has C'.hihited prooftc the t crmit I.—Alin` (fticC. ill_(:.K(1\E: li,`;l R.1\.l'I_; ❑ i3t,�l) ❑ 1ifF11•.R ❑ I.`ipc�il.Y:i ..'i'['lqti, .A1)(IC'/ [Ile ;1!/;11,9 ;1?1[11)1?7!//11/'.9' 1JI7/'i,I7//'j', ;'[tlr !/1P ;!1J0r,nllfloll on . 116 /!I)/:GYI%17//1 !,) �1'I!.' • t r /,• a il't'lltil'l': ���+f✓ (�!A__r/T 4rLA ;;ii.:,ra1P"l' — :!; ,; ,cii,: ,r.lc.. ,nr _ ,•i,11.1 .l; rlr r,,., 1,:, ..,,nrl, . „rc --yr.r-dzd�d^� Address. 3u.s. TO. o.�)� �It. Tt_I. 2. `tieeurity S�, tern G:ntractor License rCquircd tier this l,(,rk, it applicable. enter the license number hrrC: OWNER'S INSURANCE NNAIVER: I :un at5:u"C that the Li,:Cn:eC d[: - nos huvc the IiahiGt) insur,tna_ iuquirud by law. By n1) -:_'nature btdotir. I hcrehy Wr iivC this I-CquirCm<nt. 1 ,1111 the (Check one) ❑ .>a9ncr ❑ u�aner':> .uz nt. Owner/Agent a-. L11T q , uuunirr,• mN1(' 111c1L I)e 11'Lill u[ i)V [[IC N/ fI'i No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot'Tubs Generators KVA No. or Luminaires Swimming Pool +kbove ❑ In- ❑ , o. o mergency Lighting JI nd. rod, Battcr� slits_ No. of Receptacle Outlets � No. of Oil Burners '!FIRE ALARti1S rYo: of Zones No. of Switches No. of Cas BurnersNo• of Detection and . L Initiating Devices No. of Air Cond. Tons No. of Alerting Devices No. of Ranges No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained otals: D etection/A lerti ng Devices No. of Dishwashers S ace/Area "eating KW P' g Local ❑ Municipa Other Connection � =s.=z._„=.—_-::_-:--:.2.222._.,_.-,:2.222_: No. of Dryers Heating Appliances KW Security Slitems:* No. No. of Water No. o f No. of of Devices or Equivalent Heaters KW Ballasts Data Wiring: _ -_Signs No. of Devices or Equivalent No. Hydromassage Bathtubs No, of .Motors Total HP Iclecommunications Wiring: No. of Devices or Equivalent 111 Ill EK: .laeirh,i,lt6[1,:rtu�:A,1,i;i,! Irs,i'(d. •.r,i.i'rrluilcJGt Fntimated Value of Electrical Work: (Gk hen required by municipal policy.) 1kork to start: In:,pcctions to be requested in accordance with EIEC Rt11C 10. and upon ComPICtion. INSLRANCE COVERAGE: L•nless wakcd by the o9vner. no permit Cor the perlornumeC OfeleO•ical work may i,AIC tulle,: Ihr licensee jlro9 ides proof of liahility incur dice includim-, ",.,onlPletCd operation” c �aera�C or its >.uh,tanti;tl equivalent. i h nder,i,.11cd ce'rrifiet that'.uch co9cra^e in IurcC. :111d has C'.hihited prooftc the t crmit I.—Alin` (fticC. ill_(:.K(1\E: li,`;l R.1\.l'I_; ❑ i3t,�l) ❑ 1ifF11•.R ❑ I.`ipc�il.Y:i ..'i'['lqti, .A1)(IC'/ [Ile ;1!/;11,9 ;1?1[11)1?7!//11/'.9' 1JI7/'i,I7//'j', ;'[tlr !/1P ;!1J0r,nllfloll on . 116 /!I)/:GYI%17//1 !,) �1'I!.' • t r /,• a il't'lltil'l': ���+f✓ (�!A__r/T 4rLA ;;ii.:,ra1P"l' — :!; ,; ,cii,: ,r.lc.. ,nr _ ,•i,11.1 .l; rlr r,,., 1,:, ..,,nrl, . „rc --yr.r-dzd�d^� Address. 3u.s. TO. o.�)� �It. Tt_I. 2. `tieeurity S�, tern G:ntractor License rCquircd tier this l,(,rk, it applicable. enter the license number hrrC: OWNER'S INSURANCE NNAIVER: I :un at5:u"C that the Li,:Cn:eC d[: - nos huvc the IiahiGt) insur,tna_ iuquirud by law. By n1) -:_'nature btdotir. I hcrehy Wr iivC this I-CquirCm<nt. 1 ,1111 the (Check one) ❑ .>a9ncr ❑ u�aner':> .uz nt. Owner/Agent a-. L11T Location c� No. Date HORT#q TOWN OF NORTH ANDOVER y Certificate of Occupancy $ Building/Frame Permit Fee $ .J ncNus Foundation Permit Fee $ Other Permit Fee $ 1:3 TOTAL $ 1'.50 Check # j.5 'a 66 '10 / Building Inspector Inspector 9-1-0-3 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING nn - BUILDING r PERMIT NUMBER: / DATE ISSUED: SIGNATURE: (J24� Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 123 F�-CA 1.2 Assessors Map and Parcel Number: 40�� ��� Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Oatside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record K" t A') t, C, C. Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: T-4AJ P -r 4---zj Licensed Construction Supervisor: , ^ a r L 54' �/ (�J Ad essA 1• nature Telephone Not Applicable ❑ ;Z>? - License Number ©o Expirati n Dat A. -4 Re ' ered,Home I�tprovement Contractor ` -I LA0 Not Applicable ❑ Company Name 112 --Registration Number Expira on le AddrreJ5-// Si Lire Telephone rn SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this, application. Failure to provide this affidavit 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 K Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work I SECTION 6 - FST"AATF,D CONSTRUCTION COSTS I SL Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building141 00-D (a) Building Permit Fee Multiplier 2 Electrical ^ (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel x (b) 16 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, J(6 �� f� G , as Owner/Authorized Agent of subject property Hereby authorize P� - co it Y/Y to act on My behal ; In al matte s r tiv to work authorized by this building permit application. R // 0-7 Si natu� of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date '3511 I;Iill 1111111151 311111111951 1181�1= NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL, OF CHIIvMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ♦i '.111 V V V I VO1 1�. JVl\YG1 %,V I �n me -hue v� IGS- _ Lo -r 14 -JOHN S. ��, _ AUR�rar�l =1 34311 "Jg SURti`�-/ A PROFESSIONAL LAND SURYEYOR. DO HEREBY CERTIFY THAT THEr ABOVE MORTGAGE INSPECTION XaA /J Scale_' � 4ttJ AMERICAN SURVEYING COMPANY 77 PW(160M Avenue, Waltham, MA 02154 (5 17) 593-6477 = o �'T 2t r� t] 001 Y. FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION , APPLICANT.. LOCATION: Assessor's Map Number. SUBDIVISION STREET 237 ' )742 � TIONS OF�TOWN AGENTS: ATION COMMENTS. TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS PHONE- I bg yqq-�> yr PARCEL LOT (S) ST. NUMBER USE DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm NORTH ANDOVER BUILDING DEPARTMENT Tel: .978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: of Facility) Signature of Permit Applicant Xq -3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector V ACORN CERTIFICATE OF LIABILITY INSURANCE 08/01/200 ' PRODUCER (800)333-7234 FAX ALLIED AMERICAN INSURANCE AGENCY LLC Carlin Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DD' ;NSR 233 West Central Street Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC # INSURED James Scott Peters INSURERA: Harleysville DBA: Peters Construction INSURERB: Arbella Protection Ins. Co. 112 Vale Street INSURERc: Travelers Indemnity Co 25658 Tewksbury, MA 01876 INSURER D: EACH OCCURRENCE $ 500,000 INSURER E: r-^AICOAr_CO vTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER 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 CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TR DD' ;NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE AID t�LIMITS POLICY EXPIRATION OF ANY IND UPON THE INSURER ITS AGENTS OR REPRESgkTITIVES. AUTHOR!:: REPRESENT IVE V-, North Andover, MA 01845 GENERAL LIABILITY CB8G4305 01/31/2003 01/31/2004 EACH OCCURRENCE $ 500,000 X I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE M OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 500,000 A GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY PROECT LOC J AUTOMOBILE LIABILITY ANY AUTO 29888400001 01/19/2003 01/19/2004 COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ 100,000 B ALL OWNED AUTOS X SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ 300,000 PROPERTY DAMAGE $ (Per accident) 100,000 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND 7PJUB679X36iA02 10/ 12/2002 10/12/2003 TORY we sTIMIT EE C EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS f`COTICl/'ATC unI nGv RANRFI I ATInN ACORD 25 (2001/08) r /T @A RD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of North Andover BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Attn • Building Department OF ANY IND UPON THE INSURER ITS AGENTS OR REPRESgkTITIVES. AUTHOR!:: REPRESENT IVE V-, North Andover, MA 01845 y (LM2 ACORD 25 (2001/08) r /T @A RD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an emplo er providing workers' compensation for rry employees working on this job. Address -e— L,rry: rnune *: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of aiminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment.as_weU_as_chdi.pienal iesinlheiaun-da-STOP WORK ORDFR.and..a.fine-of-($IADD D)-arlayagainst.me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 0 I do hereby certify urger the pals and peva)(* of Perjury that the information provider/ above is true and correct. Print name f Phoned 21 —2S415 - Official yS Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept E]Check if immediate response is required Licensing Board p Selectman's Office Contact person: Phone #.• E-1 Health Department Ei Other :E IBJ -M 00 N h r P1 c � 4z J Cl) m Cl) 0 m c F d CA Cl) 10 0 CD n Z CA CL C CO) O n c c CD CDCL o Q9 %oc d CD CCD O CCD C CD y� CD CZ CD O y CD CD F v CA O � Z CD O CCD O CD C C = p _ O N o Q N d0<O .a W Om 0 m C) H C n a n � m Z ?-0 H o.O.► 0) 0) O G TI CD p O H O y o f �m : C _ > > m H m O .Ort Oco .Or. 0 O O C y: n mCL O Cn o H ,amON gr i.: C7zH < C C, Er C y O 00 3E 2 :CD c Q c 1' •� C2 o :INN n ;o� \ CA z � CD Oq c n CD ? CD W CLS: o 0 o pi c m cn O � d rt (n o a1 " ti Irl °� 7J G T �, •r] N 'y� 7. �7 �" r •v 2L 7d r �.7 C Z CA m °� n 7d r. O G w Gi C) z ^ n O O a g o 0 bi z O )psi 0 9 0 c Date ...... X-/', .: ......... s °:<�``° :•�'"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING s � �•" a This certifies that ....%........!.............:....`................................................ has permission to perform :...:....., :'? ,. ?...................... wiring in the builddiing of ...... �............. _�....r.,:. �................................. at ...... ..... ./..�'............. �..., r :..., . �i : , North Andover, Mass. .:........... Lic.No:., �.,✓.�... �.v: _ 1..��........................... / --' ELe� efRICAL INSPECTOR Check #— (� Official Use /Only p "F Permit No. V -A4 --t 4 P Sadeo Occupancy & Fee Checked O 4 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 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 , 'F 3 Q-P.A G^ A" ^nv Owner or Tenant Ls, �A Owner's Address Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building g2 U,4Vk0( kn (li & Utility Authorization No. Existing Service_..Z Amps Voits Overhead ❑ Undgmd Q01' No. of Meters New Service Amps Volts Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work O40 CC i 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 NO = hjww&laRuk(ed valid proof of same to the Offi ES NO = if you have checked YES please indicate the type of coverage byecking thea roRna�te ox = 9 � SURANC = BOND = OTHER (Please Specify) A86 ,l V ���LP_ ke►� �f t�"k V"T N'ew " r" (Expiratft Date) Estimated Value f lectrical Work$ C / Work to Start 12 Inspection Date Resquested d�/ S Rough 4& C 9 /final Signed under the WaIU2 of p 'ury: FIRM NAME 9^ LIC. NO..� .q�^ Lii ensee A�t/R A 4 �'�A �'i� Signature�� � � LIC. NO/---�e�� C.�P,094-.1 // /� Bus. Tel No.�j f �U 0 AddreS�_C-, // ' L� ���c Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware t the Licenses does not have the insurance coverage or its substantial equivalent required by Massachusetts General Laws. And that my signature on this permit application waives this nqulrement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse 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 Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Initiating Devices No. of Ranges t Total � No of Air Cond d' Tons Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No.of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of p Ts HeatingDevices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Si ns Bailases Wiring 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 NO = hjww&laRuk(ed valid proof of same to the Offi ES NO = if you have checked YES please indicate the type of coverage byecking thea roRna�te ox = 9 � SURANC = BOND = OTHER (Please Specify) A86 ,l V ���LP_ ke►� �f t�"k V"T N'ew " r" (Expiratft Date) Estimated Value f lectrical Work$ C / Work to Start 12 Inspection Date Resquested d�/ S Rough 4& C 9 /final Signed under the WaIU2 of p 'ury: FIRM NAME 9^ LIC. NO..� .q�^ Lii ensee A�t/R A 4 �'�A �'i� Signature�� � � LIC. NO/---�e�� C.�P,094-.1 // /� Bus. Tel No.�j f �U 0 AddreS�_C-, // ' L� ���c Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware t the Licenses does not have the insurance coverage or its substantial equivalent required by Massachusetts General Laws. And that my signature on this permit application waives this nqulrement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ (Signature of Owner or Agent) THE COMMONWF q LTH OF MASSACH USETIS DEPARTMEATOFPUBIICSAFM Permit No. BOARDOFFREPREVEVHONREGUTAHONS527CAM]2:00 APPLICATTONFOR PERMIT TO PERFORMELECMCAL ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) / r-6 Owner or Tenant Owner's Address s_GYj�A C— 6 � Is this permit in conjunction with a building permit: Yes Purpose of Building Existing Service Amps�Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Office Use only & Fees Checked �t{ W4 To the No r7 (Check Appropriate Box) Wires: Utility Authorization No. _ Overhead M Underground Overhead rI Underground No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total nrnc ALARMS No. of Zones f Detection and ating Devices 0,3 f Sounding Devices Date .................................. F Self Contained ction/Sounding Devices Municipal Other NORTH Connections o;<«•°,;•.',"oo TOWN OF NORTH ANDOVER - . p PERMIT FOR WIRING 1- This certifies that . •.�f. �.......................................... has permission to perform ..::.:.1....., .,........................................ wiring in the building of ... - - *:.....:............................................................. 1 at..Z�:•�...... �.��.���'�•• ,North Andover, Mass. / Few �`?..tri . �........ Lic. No..............I /�1.................................... CELECTRICAL INSPECTOR Check # 16— -3 46;0 OWNER'S INSURANCE WAP and thatmysigmt teonthispennit (Please chok one) OVll or YES M NO M S, pie indices the type of mWeageby w c- • ..:• n:• • ..... 1 car. Agent M Ti PERMIT FEE $Telephone No.9 LjVL/e L Location l 8`5 -UCy/ ,ani? Pi No. 8 / Date 8—/'3 _ U TOWN OF NORTH ANDOVER • i ; . Certificate of Occupancy $ 300 7SSA�NIS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 dO Check # O a C. 15736 "oCCA--� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: f c SIGNATURE: Building Comrrlissioner/IEt2Stor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number A 1 f �Li�K MAA 0, gr-(,- ,- 1.3 Zoning Information: Zoning District Proposed Use 2.2 Owner of Record: Name Print 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft SECTION 3 - CONSTRUCTION SERVICES Front Yard Side Yard 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Rear Yard Required Provide Rapired Provided R 'red Provided 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1.7 Water Supply M.G.L.C.40. 54) Public Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ?�, On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 'Y �� LA C" Name P ) j p Address for Service: 69— GF6 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ I Addition ❑ Accessory Bldg. ❑ I Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: X" c1-1 u -Q !mow R'00 r ��Q n_ c L wt Atih Pa f �w W L I SECTION 6 - ESTIMATED CONSTRIiCTION COSTS I Item Estimated Cost (Dollar) to be Completed b permit applicant OFFICIALUSE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction ©i 000 3 Plumbing Building Permit fee (a) x (b) —� 4 Mechanical HVAC() 5 Fire Protection 6 Total 1+2+3+4+5 Check Number JE(;11un /a V W1vEK AU 114VK1L,A'1"10A TO HE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si tune of Owner/A ent Date Mn NO. OF STORIES o2 SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVIBERS OT 2 ND SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner .(978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DA JOB LOCATION K- Number Street Address 35 Map / lot "HOMEOWNER Name Wome Phone l Work Phone 'RESENT MAILING ADDRESS `� LAI i City Town State ZIP Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individualfor hire who does . not possess a license,. provided that the owner acts as supervisor. (State 8u4dng Code Section 108.3.5.1) .DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or Mends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached sbuctures ac- cessory to such use and/or farm sbix:hm _ A person who ooh more than one dome in a two-year period shall not be considered a homeowner The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, bylaws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she M11 ' comply with said procedures and reo,rirPm HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL £,` CO m CD 0 m CCP CD CL v O to CD= _ CO) 10 CD 0 Lrn CA .O d d O _ CO) C�M 0 C CO) CD 0 _ CD -�v CD a. y CD CO2 Q ..y O CTy 5. o $ CO2 -1 ?m 0 m C7 m CD Ci n T Z N• O .* C =r -c h 0. .-f O .•► Er CL C 2 T .. Fn O O O = y N =r co m S > >� O U2go � C ti COY • m 'A q =r _ ay CL r�^' � o VJ O N C CD o m r A. r70 humg H Y O m ,1j�.�C�.,j dl eY V V C. d; O � T CD co Go 0 oCA �--� *4&A ? cn VJ O CD H :� N -C n- :a O RE •� c o cn 00 cn W 0 w oGa w oGc Cr1 � �cn A .y w ^ C 91 o rLrD /V ►z-3 � H yy H 0 O C tD .A `Location ��3" �-�-„,,�,�I� �'�..�^^'"'"� r No. r Date �`� ` �oRTM TOWN OF NORTH ANDOVER OL ` 9 Certificate of Occupancy $ cMus Building/Frame Permit Fee $ s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $— Check # /0-? %� i6”36,5 �'l,G � Building Insoe-pior t/ ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: to I Pat SIGNATURE: A61w.�46�.� Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 23 r &-A)Qj fidolql03 1.2 Assessors Map and Parcel Number: ,r� _ 0 %laP Numb Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Regaired Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Infomrdion: Public 0 Private ❑ zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System; Municipal ❑ Ou Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT = { ' ismcti = `> 2.1 Owner of Record 773-M ), AC .�'rt g ^' /&:3 %4 (---X6d Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ��: j•� �LC� �� A4t/L Address 0 Sig reV Telephone Not Applicable G License Number -- %C Expiration Date 3.2 Registered Home Improvement Contractor A%L ki 6u� Not Applicable C Company Name t1 Registration Number a C Address V29 ` I ��� Expiration Date Sin re Telephone x C s n C 2 R C r r r SUNNI ^Z YI SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will:result in the denial of the issuance of the building it. —Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Descri tion of Proposed Work check au a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg(. --"'t1' '.'Nin lition ❑ Other ❑ Specify Brief Description of Proposed Work: S'1 o,� + 0z 0(D I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed bpermit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) cd ��� 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, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date I, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TUABERS 1 2 No 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t-', IP N I/ 00 z It 1 ui CL o c� o ` C N O C V CL C CO cO Z O 0 C : r i:+ O � Ea D _o r 15 :r o c N C o m cw �s m C fa W mo o Z' 3 H CM 10-0 C .m _C N A D o CLC.) l mo .. o c 0Q • cr cc w o v '� Z w co m0 ac _ `0 :a*- o H CO) "-' CO W C00".0 � O � F. M dt W C o +- uujE W Cm a0.00 C.3 0.00 o� CLO. m g 0 O z U 'v v I G C CA O� m � MA O O 'E m m it H� �3 O � � L CQ Ca O G CL 0 O O G Z CD 0 CL C3 h O G G C. (A LLI LLI C4 1. W 0 W U) a a a � o a UW � A m z .o o u• � w° cL°' U w w a � w w a°' a°' r� cn cn ui CL o c� o ` C N O C V CL C CO cO Z O 0 C : r i:+ O � Ea D _o r 15 :r o c N C o m cw �s m C fa W mo o Z' 3 H CM 10-0 C .m _C N A D o CLC.) l mo .. o c 0Q • cr cc w o v '� Z w co m0 ac _ `0 :a*- o H CO) "-' CO W C00".0 � O � F. M dt W C o +- uujE W Cm a0.00 C.3 0.00 o� CLO. m g 0 O z U 'v v I G C CA O� m � MA O O 'E m m it H� �3 O � � L CQ Ca O G CL 0 O O G Z CD 0 CL C3 h O G G C. (A LLI LLI C4 1. W 0 W U) Workers' 0-c� L5— a The Commonwealth of Massachusetts Department ofLidustrial Accidents Office of ftlllesiigations 600 Washington Street, 71h Floor Boston, Mass. 02111 tion. Insurance Affidavit: Buildine/Plumbina/El Contractors Lstate: zi:0ci V - hone # work site location (full address): / !1 c�1!'7'�� ❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel ❑ I am a sole proprietor and have no one working in any capacity ❑ Building Addition _. .: .. _... ..r .. ,,rr 4. ..i �5�� :.1 .vii �_� .il. °F:i;., �(usl. :!�. .•! "t:: t: ❑ I am an employer providing workers' compensation for my employees working on this job.. company name: / '7 �-L- (f AL 7& i . address city /-1 Cyhone4: insurance. co. �; :,`7"':L'.(.. .. _ . -.. .-nnlicv 0 - 0 ` �. lor.P. 1..2cio 3 LJ 1 am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: comtiariv� name: Failure to secure coverage as required under Section 25A of 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. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby cert 1111 the pat and pe alties ofperjary that the information provided above is trite an 1 corre t. Signature Date Print name Phone # official use only do not write in this area to be completed by city or town official city or town: permit/license # ❑Building Department ❑Licensing Board ❑ check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone #; []Other (revised SCPL 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", 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, constriction 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 section 25 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, 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. ':F;'" c,�y,;. �r;,�a'��:'; t r Ali! "tar°j! � '4-B;�ia - �aE �`f�,r€a `�`t�"�:"i 1i'�..��`�'�r'����!�-•`�'°�' ', '�%, s-. �1.�ti r;>�r a� . +�-+,�'g.��i a� a•!— ,:� . o,��- b r. y.N� C C# _�[ � 1'J21{8�,,,4 �. -• i Y� y�,�14 .h `'4 V�S �dC�l� � SY `�i�--.'' • �. '3�e� �: ' Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 wbrkers' compensation policy, please call the Department at the number listed below. or Towns 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. The affidavits may be retumed to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. - ::�.,. � ::,rv. - '�u..' , nSi�"' ;,,.' ,. f::':::�::; -:ti,:i" � "1%ki+;�:, "St. %• S,�•`�n.:7��`w'?f�. _.`+r. n t obi{,• � 1 =.1 +�hE Se.Yr'iiJi�i:u.,.i4 �.._!_� h�. 7.��•+�rr -.'li.: - .at..:{ •si� aP�;dhibS:ke�,F,.e.,. ti=:��N:,,,F„it:1�.3rvz sa?3:La�::w�... ;�-��,9 ._4 cs �- - The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`b Floor Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406 3( ,W!I,m Chimneys Residential & Commercial Roofing All Types Of Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work Mass Toll Free I * Roof Leaks Experts.* Licensed & Insured L.ocally Owned & Operated Since J976 1 -800 -WAIT -4 -US scally License #034200 (924-8481) IKO® 40,Zff Wacm We Work Year Round •C Rmd, US! 1 I Proposal Submitted To Phone J7 Date - L Street Job Name City, State & Zip Code Job Location Job Phone L) We Propose hereby to furnish and labor in accordance with specifications below, for the sum of-. S17) -1T /V11 ['0A Dollars ($ v GIICAVC-7-4 SsV/Z (7Rr1--AJ B 19A 2-0o All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices. Any alteration or deviation from specifications be- Signature: low involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal may be or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. withdrawn by us if not accepted within3� days. Our workers are fully covered by Workmen's Compensation Insurance. We hereby submit specifications and estimates for: Xb ar- UrIonstall 3 feet "Eave Seal" ice barrier bottom of special and water protection along all edges of roof and tgp to bottom in each valley. #roof is stripped, we will apply conventional ice and water shield ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at per linear ft. or per sheet of plywood. /Install heavy gauge aluminum drip edges along every edge surface of each roofline. U/Cover entire roof (s) with IKO oil 89 1 " Fmw* s, premium grade shinyl (Color of choice) C, L: VR Q CA— 6miocrki r-)4cl 4 r r& 12"Replace all pipe boots where possible. U/Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied. Remove all work-related debris. 2r'c'ontractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. ULocal current references and proof of workman's compensation insurance gladly given. U--R'p-Ma rks:rA C .) T 4- 1; 31,i -t I ( Q,46,e4 Al ley l- 7-0., A) -13 GC \3 ET -rc C::' -t LJA re -,n 41WA", 'C'n k QJ1 jw R,61 6, Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Signature: will be made as outlined a Date of Acceptance: 57ST3 Signature: V- 3( NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: �C boo /Z ��5 0 ��'-✓� (Location of Facility) Fire Department Sign off: Dumpster Permit of Permit Applicant Date