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Miscellaneous - 2 ALCOTT WAY 4/30/2018 (2)
f2 ALCOTT WAY 210/025.00016 0002. A i I I 4 Datej(,../,.4.............. OF NORTh,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... S .................. .................................... ........................ has permission to perform .... ..................................... wiringin the building of............................................................................................................... at ........... .................... ..............Mrth Andover,Mass. FeeA�7.........Lic.No.L. .... .. ............ .......... C E"C"*'" Check# Eul A*A*L'*I'N'S'"P' Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. /2Z /1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 i (PLEASE PRINT W INK OR TYPE ALL INFORMATI0A9 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) p( Q L CCU— W a—y Owner or Tenant Telephone No. i Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service DO Amps //U / ap 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: 2 ?-� 1 V L21-9 i,./ l t, Completion of theLbVwing table may be waived by the Inspector of Wires. Trans No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and t InitiatingDevices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of WasteDis Disposers Heat Pump Number Tons_ KW No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal [I Other p g Connection No.of Dryers Heating Appliances KW SecNo.tyof De Imes or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices orEA uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent I OTHER: 7J I Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 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 of perjury,that the information on this application is true and complete. FIRM NAME: . LIC.NO.: Licensee: l A D /I Signature LTC.NO.: 6Ks'S� (If applicable,enter "exempt"in the license number line) Bus.Tel.No.: Address: 14/ t�t S��'t�� 4ye 0-1`) l,�Rcu,; Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department o 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 a nt. Owner/Agent PERMIT FEE.$ 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 d electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the r 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 0 Failed P1 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: - Inspectors Signature: Date: , PARTIAL ROUGH INSPECTION: Pass F?1 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPEC ION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass(] Failed Re-Inspection Required($.)❑ Inspectors Comments: 7' okc s= Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimaacom The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 9F 600 Washington Street j Foston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers j Applicant Information Please Print Legibly Name(Business/Organizationtindividual): ZZ2.?"f a Y s 6r-,70S I i Address: TH t$S-CL-L A VC City/State/Zip: (��c,��v I md- do r9_ 6 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ,�.,q employees(fall and/or part-time).* have Hired the sub-contractors 2.I b,j I am a sole proprietor or partner- listed on the attached sheet.* I• Remodeling ship and'have no employees These sub-contractors have 8. Demolition workingfor me in an capacity. workers'comp.insurance. 9 y p ty E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.F1 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill outthe section below showingtheirworkers'compensation policy information. f Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew 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 formy employees. Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.9: Expiration Date: Job Site Address; 6 L 2'x'7— Lit Z 4 Y City/State/Zip: (ey L'_ {�i4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certffy under the pains and penalties ofperjury that the information provided above is true and correct. Si afore: Date: O 1 L Phone#: t- — Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 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 employeils 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 maybe submitted to the Department of Industrial Accidents fo;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(ifnecessary)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. 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massac?ausetts Depa ent of Industrial Accidents Office ofInvestigations 600 Washington Street Boston,MA.02111 TO.#617-727.4900 ext 406 or 1-877:MASS.A F13 Revised 5-26-05 Fax#617-727-7749 wWmMass,govldia 1 r - r" } r b ti 4 �d Y Date....3.1.. �.f............ N°R7h,� l TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION k 8s.+cMua�` This certifies that ......!1.11.4 ........Uuea!". .......................................................... has permission for gas installation ......6..1?le.A)................................................ inthe buildings tof................................................................................................................... at.... .... la. T.. .t...r....................................-North Andover,Mass. Fee s. ... Lic.No. !�..t.... .I.. ...... . .................. GAS I4ECTOR Check# , 128 Date... ��.y....... 1 TOWN OF NORTH ANDOVER �?�• .,``` ..shoos PERMIT FOR PLUMBING j R g$�cHuee i This certifies that I&A...Ptxay-1.................................._............................ has permission to perform... . ?-. �!rc........ ............. plumbing in the buildings of............................................................................................. .................................................... orth Andover, Mass. Fee.�r . 4�...Lic. No. � ..r� �1 ........... ...�.. . .. ........... ................................ _ PLU GING IN ECTOR Check# I -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT# 8 JOBSITE ADDRESS vOWNER'S NAMEZ GOWNER ADDRESS TEL —��FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEWU RENOVATION: REPLACEMENT: 2-' PLANS SUBMITTED: YES Q NO APPLIANCES 1 FLOORS--> BSM 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 14 BOILER - BOOSTER _ _-- - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYERS FIREPLACE FRYOLATOR I _ _ ===L— FURNACE GENERATORI -- = -- -i - --I GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER _ UNVENTED ROOM HEATER I_ f WATER HEATER OTHER _ .......................__... . - - - r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 090-0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND �] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are IT accur o the nowledge and that all plumbing work and installations performed under the permit issued for this application will be in cc c w' all erti nt provisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME y - '. LICENSE# t SI URE MP I MGF El JP 0 JG PGIEJ ORPORATION©#1 �9� PARTNERSHIP[I#=LLC[J# COMPANY NAME: -l— ADDRESS sd2/72 CITY , STATE,;jjjZ�ZIP ]TEL __ of7 7 � FAX I CE 6 EMAIL �� ROUGH GAS INSPIRCTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION TES it, �� Yes No � 1 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts - Department ofIndustrigl Accidents Office of Investigations IN 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/ludividual): �7 � Address:— City/State/Zip- ddress:City/State/Zip: C t1 LPhone# Z�2 Are you an employer?Check th a propriate box: Type of project(required): 1.[�'I aim a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or p -time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.t ?• F1 Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12,E]Roof repairs insurance required.] employees.[No workers' q ]y 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they 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 the policy and job site information. Insurance Company Name;, �— Policy 4 or Self-ins.Lic.#: �( � / %(/ TT Expiration Date: Job Site Address: City/State/Zip:/JV Attach a copy of the workers'compensation-polJIcy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,50 0.00 and/or one=year imprisonment,as well as civil penalties in the forth 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 ee u er tl ns anllpenalties o perjury that the Information provided above is true and correct. Si ature• /L Date: r Phone#: -, A�62 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: c 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 maybe 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. 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 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 Conamonwealtkt of Massachusetts Department ofzndustdal Accidents Off%ce ofIuvestigaflons 600 Washington Street Boston,MA.02111 Tek.#617-727-4900 at:406 or 1-877,:MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia I MASSACHUSETTS UNIFORM APPLICATION FOR A.PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# JOBSITE ADDRESS ra C G�/ OWNER'S NAME P OWNER ADDRESS I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL Q RESIDENTIAL CLRINT EARLY NEW: Q RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES Q NO FIXTURES Z FLOOR-; BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM i ECIICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM =Ell 6 DEDICATED GRAY WATER SYSTEM DEDICATED 1 ATER RECYCLE SYSTEM i 1 _._..__l _E DRINKING FOUNTAIN -_[ ._____1 _-_--_I _...____► ._.J.___I __-____I __.__f _____j .--___i ...._..J .._ ._J .--..._J __J ._._.._ I F OODDISPOS R FLOOR I AREA DRAINl ___� _► ____J --__.J .___.._( ___� _._.6 IL-----I INTEI CkPTO (INTERIOR) .. .__.J KITCHEN SINK LAVATORY ( _ __--I -- ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET ) ' f I _ ) _ J — --j _ I — __j --i --- -- - -t URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ( I I _i d I ____j _____ ----- WATER PIPING i I I __. _i OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,aNo _1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Or OTHER TYPE OF INDEMNITY Q BOND 0 !, OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required byChapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. w CHECK ONE ONLY: OWNER Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr d accur the s7�nnowledge and that all plumbing work and installations performed under the permit issued for this application willbe In lian a wi allP rti entprf the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE# SIG A JXE iMPzr JPQ CORPORATION Eli _IPARTNERSH IPLLC� I COMPANY NAME 7 f ADDRESS CITY ✓L _—_ ---._..__..._f STATE�ZIP TEL I FAX j CkO2 EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES SSS Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i r The Commonwealth of Massachusetts - Department of IndustrialAcel6ks Office of Investigations IV 600 Washington Street Boston,HA 02111 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorstElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): GU U j Address: City/State/Zip: vt C t,, #: (a 1:2 r7- C 3 Areyouan employer?Check the appy priate box: Type of project(required): 1.P i am a employer with l 4. El am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [INTO workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] `Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t'Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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: l Policy#or Self-ins.Lic.#:� Expiration Date: ��al Job Site Address: City/State/Zip:1/U =��irfG' (.�� Qo® ��5 Attach a copy of the workers'compensation poH4 declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP-WORK ORDER and a fine ofup to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby i ur2der pins and enalties ofperjury that the information provided above is true and correct. Si afar : �- 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: d Information and Instruction s 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 j oint 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 employes." 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 maybe 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 perm t/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 ConnxpOnWeajth OfMassacl?usPtts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tei.#617-727-4900 at 406 or 1-877 MASSAFE Revised 5-26-05 Fax##617-727-7749 www-mass,govma II i .WEAL H SSUMETA ` EYP � I E 4 i POWER 17 CK RDUr MA 02171--181.1 01/28/15 •. YAS, f AM OF MASSACHUSETTS Alc A 9 PO� 1 1tUMMO . 11 ` 1 MA 02171- 181,`� 14 t9 0,5/01/1414 26 • i f 4`. NTROL # N5496 his license is lost o IMPORTANr destroyed, �0 'vision of Professional Licensure, otify your Board at the: Suite 710,Boston,MA 02118-6100. 1000 Washington St., If your name or address shown is changed, not' of correct name or address to insure Renewal A mailing Your board Application. Always refer to proper mailing of next This license is subject to the provisions of the General Laws Your license number. as amended.It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your Person or posted as requiredby law. WARNING HIS D066MEN7 HAS �.... , -ENHANCEDSECUAITY'FEATURE-S r CONTROL# H 3 4 0 41. 8 f r IMPORTANT •`,j 'If this license is lost or destroyed;notify your Board at the: Division of Professional Licensure, 1000 Washington St.; Suite,710,Boston,MA 02118-6100. Y f .:If your name or address shown is changed,notify your board " of correct name or address to insure proper mailing of next �r Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Law r as amended.It is a personal privilege,and must not be loarr� or assigned to any other person. Keep this license ort . person or posted as required by law. E/ ENHANCED SECURITY FEAToRES TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Cate Received "V Date Issued: _ f' T . A ticant must cam tots itcr o �s ago , x.��t t \#��? ti Aw�Y:: 4 .<,'4r,..�sk&.2 '3 stYiz y1`�?r. t �az,,.�,}�,k `xc?� �?�so �}4y,;., •ti - '�y. W.tu�x`,`�t�'s.Z•, �s.,j4t.. }v'z`Ss'"a,eE��� � Y ,. ,.: OC O '`. ., 4.-a,"p. ik:, ,,..�=,,.a ��� h'u U„3 ._,,..�a,`»�s�?"vu`',.�`:�L"rk�� ��iziR,`L� , �a}`wn.,fi'�``,xo'}rt�`~sk '�,x°,~�,.c. 1 .,,,-t, 4^+, gr;a� �����<,}'a��a.�� 1�l�,ty ',y�•.L 4 wrz,{j) ” t„'',l",`Yi~,;Y{t FY,q., t`ua�., < ,£M to.^: �.,.,.,_ ,�. k... .r Po v,.:. ..y..<:4x S...r. .;. �. x-u. ..k.k� ,. f� .,. • ,.w.:.,,-.. l t.�{`*;o,.k�:�rk� �la`.- �k'Ylssi??^t ::�;.}„a 1>, t,... `•r, #r^S rt x�,:;Vs �§. �`'a b ... ”;k”.}..rw22yY,. ,,,...::(. �Y�, ,z, xv�,, ;. .:.. '�. a�Z. }�-„ ,\�2 �.'Sn `v�`t, ,,e;�£1;t.t s4Y.,r+#'J,..rY: x�x�y�h6,Ys,,.,z. ,i it?3#',��',ravttt�}�a ~ `xt.. fel,t. �,.�r1'?v's,'a,.`t�Z.{�S `ti`:,'��.y= ���• l 1 t'.��'.,v. ��t�Y�`} �2;$l'� 'fit 1�'+t4r ^,rs 6 ( K' :,Ytex r!t�sx1�}t��R�z. :,, t�'aix`it,Y,:;+ r,.z�*,`. ,,., w w x �'�':-x, x �x..,;v •} .: ,r. .., ,.x;.�• w,"'.:.:"^ ^,.:...x. .-•u,�,3i"`°� :t,}`,,<„4Y.�<'xc,.�:.Cii;u,i,'r t;x,.,4,..,S �": Yt,��tlt#"3' }¢ t...",��`i v� ,. t�yta��y, �*.�, 4` ., " � `uE y �. ,x,.. .`�„•^S� .,. .,, v, ., ,a ix;tsys,,�z'is. �=4YY4t'.. .w`�,i�. Y{ , r p� D ..�x,t t{z 4.. `•a v ~s,Y Y:: ,�., s 4 z., y1 hv.. � �., ria M.,x', ,,:+„ t, ,. ,... S. i �, r,`a}v=z 1 ?�:�t U, ,ya,,.,vS 4 J" '.J, Y �. %4...,a x 'n, tc�� ..1 � t�. 1 1 3 }.�} ;,, u • �Y'.. '�. ,p} �y e .,...v,.. 1 ita. :�S -5 ...ky f .'t4:'; 6 } �` { i.�:Y � ...1 � �S f�.`x S i t,''1, „�.. ti � :. kl ,fig„ 4✓ .,. 7 ,^`R: c;,n,: TYPE OF IMPROVEMENT. PROPOSED USE j Resid tial Non- Residential ❑ New Building V6ne family ❑Addition ❑Two or more family ❑ Industrial ❑Oteration No. of units: ❑ Commercial • Repair, replacement E,Asessory Bldg C Others: ❑ Demolition i2-Other 11 so,R„i i�3�v t �t'j`:. �,!s f�4 'i ,a Y4 1” n�, WF,iRtei A�w 1iTt64b✓t �- +, s t5? `'wn'Y� `k} 4 y ,x'ici`sa"tw`A'3, xy"li'}x*\fiY`i}'us,\'{t5", ❑ VQ0�ew,e§ DESCRIPTION a [ * $; :.}5}f t4p" ttpY' OF TO BE < t t �.� dentttatfrx l ' ' t car° iktt Clearly) OWNER: Name; Phone- Address: h n -Address; # , a Y x r� z,es "sx,fi`t}as~~t3'tt<'sze,t3 h � k CONS a s § r s ` s a a4 3t> „'�ls~• t 5 �: }�'ttt' t�.ykt "` Y sFy`�'r ,.x�r`,tsz} 4i 4 r }ya : `� i #:t 4 Addre r z t ss;h `.`/ r 1'tYtttx' .t� Yasy 7: r s'trhi3rsrf 1::. y ;, sr}t~;.:r✓t t.z,E` xtiJ{a�.xss z e v,a `. r` t i 4.:�.:. Y 7 3Y' t r .jtznrZ#5.1i.UAF3Yro x,.'r',z~2 �t�`i,�"xl,}zS t scat z�`"s1s ;"t.1�}zv.` 'Y`�':Y�`f4�..4z4�.:�� "•4. `clry`l.,,rtes 7 .Y{�. apt K :3 �'F s s z 'z Superusr's ns rcl £ rt Pya t y r ARCH I` ECTPNOINEEI Phone: Address:_... ._.__ FEE SCHEDULE:SULDING PERMIT'VZOO PER$1000.00 OF T° TE TAA ESTIMATED COST BASED ON$125.00 PER ,F: Total Project Coat: SEE: l Check No.: Peceipt.No.: NOTE; Persons con cting with unregistered re contractors ctors do not r access to the guaratr�Y-ficl Signature of g aei Sig:i ur o p tra to�8- Plans Submitted LJ Flans Waived El Certified"Plat Ilan n Stamped Plans' J Location S No. - (_ Date o • TOWN OF NORTH ANDOVER / u Certificate of Occupancy $ Building/Frame Permit Fee ; ' Foundation Permit Fee $ r' t' �h3 Other Permit Fee $ A TOTAL. $ Check � Building Inspector j -Plans Submitted ❑ .Plans Waived ❑- ;.Certified Plot Plan ❑ Stamped Plans F1' "TYPE OF;SEWERAGEDiSPOSAL" Public Sewer ❑ Tanning/MassageBodyArt ❑. Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ •Food Packaging/Sales ❑ Private{septic tank,etc._ ❑..« permanent Dufnpster on Site ❑ n THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY _ INTERDEPARTMENTAL SIGN OFF - U FORM -..-'DATE REJECTED . DATE.APPROVED PLANNING & DEVELOPMENTS ❑ ❑ f COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature I � COMMENTS i Zoning Board of Appeals:Variance, Petition No: Zoning Decisionfreceipt submitted yes-.- Planning es -Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connectionisignature& Date Driveway Permit DPW Tuvvi! Engineer: Signature: Located 384 Osgood Street FIRE-DEPARTMENT --Temp Dumpster on site yes no -Locate d-at:124 Mair Street., Fire'Departme Jt-.ignatu're/date COMMENTS_' i Board of Building Regulations and Standards Con,aructinn Supenisor I &-2 Family License: CSFA-067096 P . is r-r. MARK J TUTTAVA.LA 32 AVERILL ST- Topsfield MA 01M Expiration _ Commis�sionne'r' 12/1412015 � a C%/e���r>�in�rrarnll�•n�'f`•��aun�rr�c!!., Ofree of ConsamerAffairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 174570 Type: xpiration: 2/26/2015 individual MARK TUTTAVILU MARK TUT-rAVILLA'7 32 AVERILL ST TOPSFIELD,MA 01983 Undersecretary I I I I ` i b 10 14 03:29p James 617-625-9335 p.1 i rmruKlANI: Ir the eertmcaoe noraer Is an AuunwlvJ3L INSurctu,the p0110y(les)Trust De enaorseo. it,UCKuuAI IUN IJ YYAivtU,suD)ecT to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rig hts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT azo Avl13a Puffer Insurance enAME: Agency Inc,TncPHONE (7872 «1970 FA)[ 560 Main Street E_ e X 170 p n 1V2PT21 .COM Winchester MA 01890 Iia COVERAGE NAICA rusURED INSURER A, r s. CO. J Murray and Sons Construction INsu KE_ surance 4737 INsuRERc 114 Broadway ; ` vel s ins- Co. 9357 INSURER D: SomervilleINSURERE: MA 02145 INSURER F: COVERAGES CERTIFICATE NUMBER_CL142403888 THIS IS TO CERTIFY 7HAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM D ABOVE VISION g OR-THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR L LTR TYPE OFtNSURANCE AVOPOLICY EFF POLICY EXP GIENERAL LIABILITYMMIDD/ NM/DD UNITS FFD EACH OCCURRENCE000,OOO COMMERCIAL GENERAL UABILITY SUBS A CLAIMS MADE apCCl1R PREMISES EaDomwence T 100000 fP:')L:Ir_yNUMIIFR 2/27/2013 2/27/2014 MED EXP(Any one person) S 5 000 PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GENL AGGREGATE LIMP APPLIES PER; X POLICY PRO LOC PRODUCTS-COMPIOPAGG S 2,000,000 AUTOMOBILE LIABILITY S C WBINED INGLE LIMIT B ANY AUTO Ea amideM 1 000 000 A LCIM.IED X SCHEDULED RCOD001002944 BODILY INJURY(Per person) S X AUTOS /18/2013 /18/2014 BODILY INJURY(Per accident) S HIRED AUTOS X NDN-DMED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAR OCCUR Underinsured mDloost Bl a it S EXCESSLWe CLAIMS44ADF EACH OCCURRENCE S DED RETENTIONS AGGREGATE S C WORKERS COMPENSATION $ AND EMPLOYERS!LIABILITY IMC STATU- OTH- ANY PROPRIETOriWARTNER/FF.XECUTIVE Y I N OFFICERIMEMBER EXCLUDED? ❑ NIA E.L EACH ACCIDENT S 100 000 (Mandatory b NH) BUS—SB90393-6-13 /30/2013 /30/2014 Ir Yyes,doscdba under E.L.CISEASE•EA EMPLOYE S 100 000 DESCRIPi1CN OF OPERATIONS below EL DISEASE-POUCYLIMIT S 500 000 DESCRIpi10NOFOPERATiONSILOCATIONS IVEHICLES(Attach ACORD101,Adr&tlona1Rena"Schedule,Irmorespacelsrequlred) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 2 Alcott Way North Andover, MA 01845 AUTHORIZED REPRESENTATIVE (2O1J oosT.cj 5) ohn Axilla/AVILLA iNS02S ACORD uj O0 ©1988-2010 ACORD CORPORATION. All rireserved. ghts The ACORD name and logo are registered marks of ACORD NORTly Town tE? _.. : :_.��. � Andover 0 No. WSW AKG h ver, Mass, I 4 cocIc«ewlcw 1' U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THATBUILDING INSPECTOR ..................................... ... ................. ......... ......................... ..... has permission to erect.......................... buildings on .....�...........I,�x. ..G�.. ..,.,,.�-1' ........... Foundation � I n Rough to be occupied as ........... .........I ... ............... y provided that the person accepting this permit shall in every respect conform to the terms of the application Final .on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT1,T SJOTS Rough Service ................................................................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 259000.00 m $ - $ 300.00 Plumbing Fee $ 37.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 37.50 Total fees collected $ 475.00 I 2 Alcott Way 642-14 on 3/19/2014 Kitchen Remodel Ii �I I I 25-7111 33 tA� 2 ROLL N I OUT �' P 1�ry OF3 DOB12 TRAYS / yJ TRAY TRASHW/2 BASE / CONTAINERS T it 0 1 / G) a v D w 1 . TILT OUT j < DRAWER 00 SPICE c Q PULL T II � U) OUT O.t 2N p m ii w p O 41, ti N 44 N X I 0 N f A T n 4 ROLL o OUT p TRAYS O NOTE. ,., floo ' lan To ensure accuracy client is responsible and has •� p verified all dimensions. Any changes after the order has been placed will result in a restocking tee. i J Murray and Sons Construction,LLC i 114 Broadway Proposal Somerville,MA 02145 Date Estimate_No. 02/05/2014 902 (781)414-0605 john@jmurrayandsons.com i I Address Maja Ebiary 2 Alcott Way North Andover Description Amount • Contractor to demo the existing cabinets and remove. Contractor will demo the wall I and doorway opening into the dining room. Contractor will demo the existing floor.All disposal and removal fees included • Contractor to install new oak hardwood flooring in the kitchen(estimated 145sgft). Contractor has included sand and poly finish on new flooring. • Contractor has included the carpentry and framing necessary for the opening into the dining room. Contractor to patch the ceiling, frame the area,and plaster the walls.All materials and labor included. • Contractor to install Cliq cabinets. Contractor assumes minor carpentry and modifications will be necessary for cabinet install. • Garbage disposal, sink,granite, faucet,by owner and installed by J Murray.All plumbing for the kitchen has been included in the estimate.Any hood vent install has not been accounted for. Contractor has not included any mechanical in the wall being removed. Contractor has not included any back-splash in current estimte. ACCEPTANCE OF PROPOSAL-The above specifications and conditions are Total $9,360.00 hereby agreed upon and accepted. J Murray and Sons Construction,LLC is - authorized to complete the projects as described. i Accepted By Accepted Date 1 MASSACHUSETTS HOME IMPROVEMENT CONTRACT Homeowner Information Name: Street Address: (not post office box) City/Town State Zip Code A, A Contractor Information Company Name: Contractor/Owner Name Business Street Address City/Town State Zip Code S Kra �- Salesperson(s): Contractor Registration#: Rb _ Exp. Date: 1 f WORK TO BE PERFORMED AND MATERIALS TO BE USED Contractor agrees to do the following work for homeowner: Materials Expected to be used: I 1 - I Work Scheduled To Begin: Expected Date of Completion: TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE The Contractor agrees to provide the work,furnish the material and labor specified above for the sum of$ 37 (Include all finance charges in this amount.) Payments will be made according to the following SCHEDULE: $ Q upon signing the contract. $ by / / or upon completion of $ by / / or upon completion of $ 3 upon completion of the contract. In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins: 2 DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES /.i 7 c /� I Homeowner's Signature JC ractor's Signature Date Date REQUIRED PERMITS The following building permits are required: 2564 (7f�< It is the obligation of the contractor to secure such permits as the homeowner's agent and any costs which contractor will incur in doing so are included in the price for this job as set forth above. Please note that homeowners who secure their own permits or deal with unregistered contractors are excluded from the Guaranty Fund provisions of MGL C. 142A. Is an EXPRESS WARRANTY being provided by the contractor? No Yes The following warranty will be provided by the contractor under this contract: V I I Please note that all home improvement contractors and subcontractor shall be registered and any inquiries about a contractor or subcontractor relating to registration should be directed to: Director,Home Improvement Contractor Registration, One Ashburton Place,Room 1310, Boston,MA 02108, 617-727-8598. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest has been placed on the residence. 3 i i ARBITRATION The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as rovided for in MGL C. 142A. F Contractor: Homeowner- Date: Date: NOTICE: the signatures of the parties above apply only to the agreement of the parties to alternative dispute settlement initiated by the contractor. The owner may initiate alternative dispute resolution even where this section is not separately signed by the parties. ACCELERATION OF PAYMENT Homeowner's Financial Insecurity. A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. Contractor's Financial Insecurity. In instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the signatures of both parties. OTHER CONTRACTUAL DOCUMENTS This contract includes as contract documents the following additional enumerated documents: ,I SII I I NOTICE OF CANCELLATION YOU MAY CANCEL THIS TRANSACTION,WITHOUT PENALTY OR OBLIGATION,WITHIN THREE BUSINESS DAYS FROM THE ABOVE DATE. IF YOU CANCEL,ANY PROPERTY TRADED IN,ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE INSTRUMENTS EXECUTED BY YOU WILL BE RETURNED WITHIN TEN BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR CANCELLATION NOTICE,AND 4 -Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. -Tota[land area;sq. ft.: -ELECTRICAL: Movement of Meter location, rriast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: . -Yes No MGL-Chapter-166.Section 21A-F and G min.$100=$1000:fine NOTES and DATA—(For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The folfswing is=a=list of-the require&forms to be filled out'for the.appropriate.permit to.be obtained. RoofirAg, Siding, Interior Rehabilitation Permits ❑'" B.uilding Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Addition Or Decks a Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract i ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products j NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) i ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apu•-�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.?ted with the building application Doc: Doc.Buiifiing permit Revised 2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION � r Permit NO: U Date Received Date lssum)eh V IMPORTANT:Applicant must complete all items on this page LOCATION, �L/ 7 /mo i .� Print PROPERTY OWNER lilA T/9 _ '6 �— Print 100 Year Old Structure yes no MAP NO: _PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no .TYPE OF IMPROVEMENT. PROPOSED USE Resid tial Non- Residential ❑ New Building Ane family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑Commercial Oepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: . ,ys%lL Ne c ,) if pipg d_s Identification Please Type or]Print Clearly) OWNER: arw ,3 Phcane:_ Address +� p[¢ s t a l;. ���`��..• �?ft�r �� t � `\t���� � £ �?1��s,�#" �4y Li i ,.,�>.. �.. :J < -t r..1. � �,`$ � r',.r �.zi,.`'�.,r. .,,,- �• .� �°.L e� � 1., to �'� "s`...., 7 .z sx.',. ., �ti `��'ti 'ir � ..;•,.�, i,,,� �x� � �� `� �L� t. ��,,•. �s�rrrc �� ,, ��,a ��, �. �tiz z�z �e � � ,Y„,t u, � ti a k I $ '�,,�"��� k L�1.r.r•. 1? .:....tt3 `�{��-: S rk ,a.,��, #..�� ;. ``�"a4�"siu4`�v'`�xi" t�� '��,.�x <'y\�4�4�ac6<�s +�r"`s .>:. �, ,..�„? ,.�+ p. sr r,,� 4x i ;�},` %`i�2rk i�� •> `r �.k y�1�'`:��,,.�.. . aii'i�1si;t rl Vii,�`�, ���.. ��`�,U�X-+..`s'_.i�� ti�4x.,, n s res... s 3,; t �: �'�t.,.�.. .4.. �. >1rL a�:`:�;<. 'i` �. .�..�,{,t..?.4.. �... ...;,2,.`k... `rxa�'�. �x .:1. ,s.'Y.v 3r-�. •o-n. 'l,Fry rti L�l �xti `~,-,a� ? �'z2.�� ,.:�,... - �^ bg,....: � •::`..?\::�., u'ty �, ``k�...�.k���,•4�,r.. .ti .a.. � .F��-�'�, rt..e,�¢�„i sx ,r.�.,�}, +,r�'i�.�.. r �'.y,. � '?�2&�a.,4.,a^. ,,.. "� /,z"rk, ,,.3r l�, ,ti..p����s3 t��`a'.' �t�`.'1�:.til§ 4 S' n�,G', ��� "''=E:�tg �j\4... L``mn...},�i v nS��', {� fill„y��:�, � a r✓�,. ;+r�� �`f�3 D. � ieB!sC�r rCr� rt� � ,�� � •�, �.�r ti� .,ti t.�, wr � ,4��'L; �s, �.,E � ;3�Y”� Vii€.<r, , ��, �,r .�� c�N r,;r� �.�r,'t.' ..,..,a t a .:.r '� i �. � ..�i''.`..,.��.,� s .�.... .�.�4 .3`�., ,..s�.. a. ?r tL'.= .. ,,. , �.,.,,...• a:.:. 4;X� r.: � � ; L..t t .�., x �" �1. '{ �,'2 �,4t 3.. ��,», '�,.�..`2 •,w.-�. "t !,k, .,.,<. �\. ,. .��� `�'�`:.. �, , `Y`. ...;..,�`z`� k �."a t t�` �.}E c 1 js.. - � ti,..A �� ~L• .� 7, `,., .�. �tio..� L. 4`la"� '`r..,L.� €�;:.�, r :Y (. 4 e. .�;`�n.�`2.L���.�y.��??4.,r r o�. :���¢'�'��S t`. .,,� '�'a..,. t .a. f'�k .k e,• .4 al(. .T' : k i�'~ t r��,.. .�. ., mti n a ?�. •�.. l��l 4t`.,F.. �'L'' .�-,":. ..3 L.: �,.. 37 �,. ���-..h� :,y� .a:..•'.n ..z� r�s� k.44 S ��,�#�� `t:� `�.La,� �, z � � �:�,,. a �� '�, } Y'u'�'Z +'�s. � �,��.: r,652i' � ARCI ITECT ENGINEER_ _ Phone-, Address; Reg. No. FEE HEDU tt LDL PT"eMI'r. Iz R$1000,000F THE r07-ALESTIMAM COT 4 D ON$125,00 PER SAli 1 r C : FEE: Check No. Receipt Ne. _ NOTE: Persons contracting Wth'unregistered rr ra ct rs do not have access to t ie e r r Signature of AgentiCv�rrir ; iai f rtc I Plans Submitted LD Plans Waived❑ Certified Plot Plan tar�o`l �d Plans [ - F Location,-,/ 141,10y No. f ` Date i L� TOWN OF NORTH ANDOVER s � Certificate of Occupancy $ Building/Frame Permit Fee J9 O Foundation Permit Fee $ Other Permit Fee $_� TOTAL $ Check# ✓ v � � 2 */ Building Inspector Plans Submitted ❑ .Plans Waived-[] _ ...Certified Plot Plan ❑ Stamped Plans ❑ I TYPI39T:SEWERAGE DISPOSAL" Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ Well ❑ T ❑ I obacco.Sales -Food Packaging/Sales ❑ I Private(septic tank,etc..: -❑ - _ permanent Dempster on Site El _THE-FOLLOWING SECTIONS FOROFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i - DATE REJECTED DATEAPPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature E COMMENTS HEALTH Reviewed on Signature COMMENTS l Zoning Board of Appeals:Variance, Petition No: Zoning Decisionlreceipt submitted yes ° f Planning Board Decision: Comments Conservation Decision: :Comments t Water & Sewer Con nectionisignature& Date Driveway Permit DPW To`v:' Engineer: Signature: Located 384 Osgood Street FIRE DEPARTiIA;►ANT Temp Dun)p'ster on site yes no Located-at�124,Main Street-- Fire"De"partme. t signatureldate`~ COMMENTS ' " Enter construction cost for fee cal- North Andover Fee Calculation Construction Cost $ 35,000.00 m $ - $ 420.00 Plumbing Fee $ 52.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.50 Total fees collected $ 625.00 I 2 Alcott Way 575-14 on 2/3/2014 2& 1/2 bath remodel I I I i I i I i r t Enter construction cost for fee cal- North Andover Fee Cakulatlon Construction Cost 3500.00 m $ - $ 420.00 Plumbing Fee $ 52.50 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 52.50 Total fees collected $ 625.00 2 Alcott Way 575-14 on 2/3/2014 2& 112 bath remodel i i I I I i Feb 04 14 01:54p James 617-625-9335 p.2 Imruxian I: Ir the cernncate nicer Is an AUDI IIUNAL INbUKLU,me pollCylles)must De enaorsea. IT 5UZ3KUUA I JINN I5 WAIvtU,suo)ect 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 CONTACT Jo Avilla Puffer Insurance Agency Inc, INO . 1781)729-1980 FAX 560 Main Street E-MAIL ,JOhn@ p A1C No QuinnGrou Ina.com Winchester MA 01890 INSURE S1 AFFORDING COVERAGE NAICN iNSUREp INSURER A:Commerce Ins. Co. J Murray and Sons Construction INSURER B:Pl outh Rock Assurance 14737 114 Broadway INSURERC;Travelers Ins. Co. 3 9357 INSURER D SomervilleMA 02145 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER:CL1424 D3888 REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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 TME TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I -Am SIM LTSRR TYPE OF INSURANCE POUCYEFF POUCYE7[P � GENERALLll161LRPOUCYNUMBER Y MM/OD NM/D LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X�OCCUR PREMISES ER x7w"ance $ 100,000 OVXQT 2/27/2013 2/27/2014 MED EXP(Any one Person) S 5,000 PERSON'AL&ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GF1J'L AGGREGATE LIMIT APPLIES PER: X POLICY Ej PRO- LOC PRODUCTS-CAMPIOPAGI S 2,000,DOO Jr-CT I . IAUTONOMLE LIABILITY $ COMBI ED SINGLE LIMIT ANY AUTO Ea accident) 1 000 000 H ALL OU6NED BODILY INJURY(Per Penson) $ AUTOS X AUTpSDULED tRC00001002944 /18/2013 /18/2014 X HIREDAUTOS X qWN� BODILY INJURY(Petaotldent) $ PROPERTY DAMAGE $ Peraccident UMBRELLA LIAB OCCUR Underinsured motorist B1 s ii $ EXCESS UAB EACH OCCURRENCE g CLAIMS�AADE AGGREGATE DED RETENTIONS $ C WORKERS COMPENSATION g AND EMPLOYERS,LIABILITY YIN WCSTATU- OTH- ANY PROPRIETORIPARTNER/EXECUTIVEBY LUMMITI, OFFICERIMEMBER EXCLUDED? M .L.IA00 D00 E LEACIIACCIDENT $ (MamdatoryInNH) MM-SB90393-6-133/30/20L33/30/2014 U yes,describe underE.L.DISEASE-EA EMPLOYE $ 100 ODO DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500 000 i DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Aaach ACORD 101,Additional Remarks Schedule,U more space Is mqulredt CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 2 AICott Way North Andover, MA 01845 AUTHORIZED REPRESENTATIVE John Avilla/AVILLA ACORD of (2010/D5) ©1988-2010 ACORD CORPO INSOZS(2olatu).o1 The ACORD name and logo are registered marks ofACORD RATION. All rights reserved, b 10 14 03:29p James 617-625-9335 p.1 kPRODLICER rVKIAN I: IT the certlticate newer IS an AUDI IIUN$kL IN*LIKtU,the pollcy(Ees)must De enaorsea. IT JUbKUUdAI IUN 1S YYAIVLU,SUD)ert t0 terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the rtificate holder in lieu of such endorsement(s). CONTACT NAME: John Avilla PH Puffer Insurance Agency Inc. ONE . (781)729-1960 FAX 560 Main Street E-MAa (Air.Ne' John@QainnGroupins.com INSUR S AFFORDING COVERAGE NAIC Ir Winchester MA 01890 ENSURED INSURERA:CC=MerCe Ins. CO. 1NsuRERB:P1YZ0uth Rock Assurance 14737 J Murray and Sons Construction wsuRERc:Travelers Ins. Co. 39357 114 Broadway ENSURER D: INSURER E Somerville MA 02145 INSURERF: COVERAGES CERTIFICATE NUMBER:CL142403888 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBA POLICY NUMBER MppY EFF PM1DD EXP UNIITS GENERAL LIAEALYTY EACH OCCURRENCE $ 1,00D,000 X COMMERCIAL GENERAL LIABILITY AGE 10 R-11-1 PREMISES Eeoccimence) $ 100,000 +A CLAIMS-MADE 1z OCCUR 3IDVXqr 2/27/2013 2/27/2014 MEO EXP(Any one person) S 5'(300 r PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GENLAGGREGATE LIMI•APPLIES P0q: X POLICY 7 PRO PRODUCTS-COMPA7PAGG 5 2,000,000 LOC AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $ En accident 11000,000 H ANY AUTO BODILY INJURY(Per person) $ ALLOS�O X SCHEDULED R000003002944 /16/2013 /18/2014 BODILY INJURY(Per acciGs�t) $ X HIRED AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE I $ Per aeadent UrdannsurednmtanstBls K $ UMBRELLA LIAR OCCUR EACHOCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS C WORKERS COMPENSATION $ AND EMPLOYERS•UABILJTY WC STATU- OTH- ANY PROPRIErORIPARTNERIEXECU7IVE YIN 100 000 OFFICE RIMEM IER EXC:.UDED? El E.L.EACHACCIDENT $ (Mandatory b NH) BUB-SB90393-6-13 /30/2013 /30/2014 II E.L. EMPLOYE S 100,000 yes,describe Linder OF OPERATIONS below EL DISEASE•POLICY LIMIT $ _ SQ D OOO — -- -i DESCRIPTION OFOPERATIONSI LOCAMONSI VEHICLES(Attach ACORD 101,Additlenal Remarks Schedule,Bmore space is required) CERTIFICATE HOLDER CANCELLATION SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 2 Alcott Way North Andover, MA 01845 AUTNORIZE0 REPRESENTATIVE John Avilla/AVILLA ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD � NORTt<y Town o jAndover � z o h ver, Mass, l COC NICNl WICK 1' ACR^TE0 /.P���y S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System ' BUILDING INSPECTOR THISCERTIFIES THAT ........� '..... �'�. `.. ....................... .......... .. .............................. has permission to erect buildings on D Foundation .......................... ... ........ .I. ..+. ...�1. . ...................... / N{.�AA ............................................ Rough to be occupied as ... ..�.....� ...... Gr..!.�4 0.......................: Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final 11 PERMIT EXPIRES IN 6 NTHS ELECTRICAL INSPECTOR 0� UNLESS CONSTRUCTI TAR Rough Service ................................................................... ...... final BUILDING INSPECTO GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SODS Board of Building Regulations and Standards Construction Supury icor 1 &2 F-a niIN License:CSFA-067096 MARK J TUTTAVLLA 32 AVERML ST; s Topsfield MA 01483 I I %J Expiration Commis�sionne^r' 12/1412015 ° I �. C-'��e �•o�irrttn�rtaerr�l�arrr'.,�� �/ riuri uraclJ., _ _. Office of Consumer Affairs&Business Regulation ME IMPROV 770 CONTRACTOR Type: istration: xpiration: 2126/2015 Individual MARK TUTTAVILLA' MARK TUTTAVILLA 32 AVERILL ST i TOPSFIELD.-MA 01983 Undersecretary i I - I a. 9 " The Commonwealth ofMassachusetis Department oflndusirlalAccidents Office of Invesfigadons 600 Washington Street- Boston, treetBoston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:•Builders/Contractors/Blectricians/Pluznbers A licanfInformation . Please Print Le ibl Name(Business/organizatioll4ndividual):- �J , v (� - Address: � � I City/State/Zip: v• 6A/ •J�pholie#: Are you an employer?Check thea ro riat PF p ' box: , 1. I am a employer with 4. [) I am a general contractor and I' Type of project(required):- employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construcction 2. I am a sole proprietor or partner-. listed on attached sheet. 7. El Remodeling ship and have no employees =these sub-contractors have working for me in any capacity. employees and have workers' 8• Demolition [No workers'comp.insurance comp.insurance.$ - 9•- Building addition required.]- S. (] We are a corporation and its 10.❑Electrical re 3.❑ I am a homeowner doing all work officers have exercised their p�or additions . myself 11•❑Plumiiing repairs or additions . y [No workers comp. right of exemption per MGL � insurance required.]t .c. 1522§1(4),and we have no 1Z•❑Roof repairs employees,[No workers' _ 13•❑Other romp.insurance required.] tiny applicant that checks box 1 must also fill out the section below showing theirworkers,compen§ation policy information. r Homeowners who submit this affidavit indicating they are.doing aa work and filen hire outside contractors most submit anew 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 :mployees. If the sub contractors have employees,they.must provide their workers'comp.policy number. Cam an eitrployer that is providing workerscompensation insurance or nformatiox f my employees" Below is tine paiic}i and job site nsurance Company Name: 'olicy#or Self-ins.Lic.#: //� 9p 3 - -- -Expiration Date: 'ob Site Address: City/State/Zip:------------- kttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 'ailure to secure coverage as required under Section 25A of MGL c.152 can lead to the finposition of criminal ear im p ��penalties of a ine up to$1,500.00 and/or one-year prisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certtry under pal and allies of perjury that the information provided abo a is tr a and correct. .i nature: _ Date: 3 'hone#: Official use only. Do not write in this area,to be Completed by city ortotvn offtciaL City or Town — Permit/License# - Issuing Authority(circle one): L Board of Health 2.Building Department 3.,CityiTown Clerk 4.Electrical Inipector 5.Plumbing Inspector 6:Other r E A Contact Person: Phone#: a. I ' J Murray and Sons Construction,LLC Invoice 114 Broadway Somerville,MA 02145 Date Invoice No. 02/03/2014 I-1025 (781)414-0605 john@jmurrayandsons.com Bill To Maja Ebiary 2 Alcott Way North Andover Estimate# 1110 Description Amount j •Contractor to demo the 6x8 area of tile found in the entry way. Tile provided by client 350.00 and installed by J Murray& Sons. All grout,building materials, etc. included. • Contractor to sand and poly all hardwood found in the 1 st and 2nd level of the home. 1,800.00 Contractor has included sanding and poly for the stair treads as well. • All crown molding sanded down and prepped.All other trim found on level 1 &2 of 4,500.00 the home will be prepped for paint. Contractor to prep all walls.All trim,walls,and ceilings are to be painted. Contractor to supply Benjamin Moore paint(color by owner). • Contractor includes moving outlets on stairs and upstairs hallway due to iron work. 1,800.00 Electrician to replace fan in living room with light fixture. Contractor to fix the outlet in the garage door opener. Sconce lights to be installed in the hallway.New light added to the upstairs master bedroom closet.Heat lamp to be wired by electrician. Electrician has included re-wiring the master bathroom due to demo. Light fixture added over double vanity.Wiring moved due to layout changes.New 2nd floor ceiling fan installed.All light fixtures including recessed are to be purchased by the client. • Contractor to demo the existing handrails on the staircase and upstairs landing/railings. 3,550.00 Contractor will also demo spindles found in middle landing on the stairs. Contractor will demo the railings in the dining room as well. All debris and materials removed by J Murray.In place of the existing rails contractor will add wrought iron rails and basic posts as described during the walk-through. • Contractor to demo the fireplace tile. Contractor will prep the area for granite install. 600.00 Purchase and install of granite by client. Continue to the nexta e pg i i Page 2 of 2 Description Amount •In the downstairs bathroom contractor will partially demo.All tile removed. Contractor 3,200.00 will install new durock and tile(purchased by client).New vanity/sink and toilet installed by J Murray(purchased by client).New med cabinet and fanlight to be installed by J Murray and purchased by client. •In the upstairs bathroom 1 contractor will demo the tile and sub-floor. Toilet to be 2,100.00 removed but shower left existing. Contractor assumes water damage has caused any structural issues.New tile,toilet,vanity,provided by client but installed by J Murray.All plumbing in the scope included.Fixtures by owner and installed by J Murray. •In the master bathroom contractor will demo and open up the wall between the vanity 6,800.00 and bathroom. Tub/shower on right side to be demolished and removed. Contractor will demo all flooring.Vanity removed. Contractor assumes 75%of bathroom area to be re-framed.Bidet purchased by client and installed by J Murray.New double vanity by owner installed by J Murray. Curbless shower to be installed in the bathroom.New shower door purchased by client installed by J Murray. Contractor includes new shower drain and forming of the base of shower.All file for the floor and bath walls by owner installed by J Murray.New fan purchased by client and installed by J Murray. Toilet by owner installed by J Murray. Contractor has not included any framing of the closet outside the bathroom.Bench seat in shower to be built and tiled by J Murray.New door for bathroom purchased by client and installed by J Murray. All fixtures by owner.All plumbing by J Murray. • Contractor to replace two windows in the front bedroom with new vinyl.Purchased and 975.00 installed. i ILL Total; $25,675.00 J�r C2 F i f _ 1 JeA Dimensian Number of Stories: Total square feet of floor area, based on Exterior dimensions._ i .Total land area, sq. ft.: ELECTRICAL: Movement of Meter.location, mast or service drop requires approval of j Electrical Inspector Yes No DANGER.Z®NE LITERATURE: Yes No -MGL-Chapter-166 Section 21A-F and G min.$100-$l000.fin.e i i NOTES and DATA—(For department use �I I i I I I I Notified for pickup - Date � Doc.Building Permit Revised 2010 1 I I Building Department The fol'-)win.g is a=list of the re uired.forms to be filled out forthe;appropriate. ermit to`.be obtained. • qp Roofivg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or`C.S:L: Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster..permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 1 o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) I Li Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) r o Building Permit Application La Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit 4 u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report E o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the api)%,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building Permit Revised 2012 .