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Miscellaneous - 209 GREENE STREET 4/30/2018
O MAPFRE Commerce INSURANCE - April 06, 2015 The Commerce Insurance Companyw Citation Insurance Companyw 11 Gore Road, Webster, Massachusetts 01570 508.949.15001 www.commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MAO1845 RE: Our Insured: JUDITH PULZETTI Property Address: 209 GREENE STREET Policy#: BCKLQR Date of Loss: 02/23/2015 File#: KAHY94-HRVPX6 Board of Health or Board of Selectmen Town/City Hall Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. PAUL JAWORSKI JR FIELD CLAIM REP, SIU Telephone: (508)949-1500 Ext: 11532 Toll Free: 1-800-221-1605, Ext: 11532 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. April 06, 2015 CIC 254 (Rev. 4/95) MAIL I72 ~ti Date .... ...n... ).. fOW OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...?`...'..I.. � '......J.. W. ��...�.l..�P stn `'... has permission for gas -installation .... w �.......... inthe buildings off ......�u . z e. 6.............................................................................. at ........... .2. .......... ( .P..,lL.... " North Andover Mass. Fee bbb"v .... Lic. NoU.3k....... Nl GASINSPECTOR Check # -34 ',3 lJ 1 G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 3124/2014 PERMIT # JOBSITE ADDRESS 1209 Green St OWNER'S NAME OWNER ADDRESS I Same TEF IFAXI OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL NEW: ® RENOVATION: 0 REPLACEMENT: Ej APPLIANCES -1 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER RESIDENTIAL❑ PLANSSUBMITTED: YES❑ NO❑ fi imf mimiK , INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO ❑ 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al Pertinent proyjsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME Joseph Marino LICENSE # 8736 SIGNATURE MP ❑ MGF ❑ JP ❑ JGF ❑ LPGI [j CORPORATION ❑# 3285C PARTN SHIP❑#LLC ❑#� COMPANY NAME:j RH White Construction Co =ADDRESS 141 Central St CITY I Auburn I STATE MA ZIP 01501 TEL(508) 832-3295 FAX 1508-926-4347 CELL 508-832-4614 EMAILJMarino@RHWhite.com 1�J W F O z z 0 H U w a Q z 00 w a ZO z O U❑ �- w On ~ w o W o F a z LU 3 z w > a W w fZ d w w U a O d CA a a x F a a a d' Cd x w I-- a F O z z Ocn Fr U r 1 - '� to z rA C7 D O a aneu f S r: 'P('r� CO LL Ln N� N •LU Ir< LU, ��,. • 1J�� trLl:�:;�,,.., fYri;i::j1,%',,r .:�f .•�i�;`�1{;}iti':��j��r^'<c:LJa[,1'�i'_`G, Gr�;l :•`i:(.'::1'�IY'='�i . ,O'-�tjl 'tit:tt�t�l't`t'{i,,.,.it�}�.�:ia:.!':T.L.S �.�!,��Q�.,..�,, • •'cif .r i : ''�'rf,;'. ".:Ji�'rir',.;nM�.�li: `ill. r... ,t,`,''��:i�l r.:, ';1• i�•1�.iff .r .r •, tt.i¢fl ;f::`;,� 1+1:�;.r.,... .:ii3-.....`:��..+..•.:!,.f:';:'7:":'.',..,.. fF,r' il�:tlir�: E • � �'%; .- !`'. 'o�}u'i"ir"r..l'';i.i i `;r ':'i4 iiif:.' ;:i.:. jEl„'.ilii ' J' tLY1'Z d ' WLU z w� Qz .U' r^I LL �� Id r\ -'t • �� Q H� O W �. 1L1 � luj< Lu LD AO - �r �'� �1�'•� .�.: lf:�fi: I.Q i�.�. tr�i``:..riri�i goy}� ::V/i ` ''�:':, `:LL'i'•. '.FYI`,.; ,::y' ilfF: .i.tn I��i '.1:1`I�iiiiiii 11 l:: 41.x' 1 f i ;Jill .::i • :�ij..ri :�': 'l:.t lrrtf' ''i1� iii t L.r- , r`���i' .., :iu;`.11-;%� tiyi'..r:''a;r:.!�d•. %r:r ::,,1' E �s �® CERTIFICATE OF LI pppDATE (MMMDNY" ABILITY INSURANCE page 1 of z F08/29/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ims)muat be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does notconferrights to the certificate holder in lieu of such endorsement(s). Willim Of Maeaaehusotte, Inc. C/o 26 CRAtury Blvd. F. 0. Box 305191 Naghville, TN 37230-5191 R. H. White Conaseruction Company, Inc. 41 Central 6treet P. 0. Box 257 Auburn, MA 01301 "o-uIr G'F I -ib�^ isra I wo NO)l BOB -467-2378 - oR�S,s� cext:ificate�r�willis.com INSURER(S)AFFORDING COVERAGE NAICn INSURERA:The Charter Oak Fire Xnaurancg Company 25615-001 INSURERS:TrcV41mrs Property Casualty Company of Am 25674-003 INSURER C: NatiOnAl Union Fire lnsuraneo Company of 7.9445-001 INSURERD;Traveleaa Indamni,ty Company 25658 -DDI INSURER F: VYGICHVGa ctKIIFICATt NUMBER: 20287680 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. A GENERAL LIABILITY X COMMFRCIALGENERAL LIABILITY CLAIMS -MADE OCCUR AGGREGATE. LIMITAPPUES PER; AUTOMOBILE LIABILITY X ANYAUTO ALI,OWNED sCHROULE[ AUT08 AUT08 X HIREDAUTOS X NON-OWNEI AUTOS X Comp DeflFy--IC911 Ded LLA LIAO OCCUR C X EXCESB Aa CLAIMS CLAIMS VTC20co 977X9948-13 9/1/2013 9/1/2014 EEAACMHOCCURRENCE PRENg(Eeoceu 2cf MED EXP (Any oneperson). PERSONAL&ADV INJURY GENERAL AGGREGATE PRODUCTS-COMP/OPAG VT.TCAP 977K955A-13 /1/2013 9/1/2014 1 J�-INED5INGLF,I.IMIr 838766140 9/1/207.3 19/1/2014 BODILY INJURY(Perpemon) $ 60DILY INJURY(Peraccldenl) ;S AGGREGATE DED IX IRETENTIONS 10,000 D WORKERS COMPENSATION VTRB 8205A185-13 9/1/207.3 9/1/203.4 XAND EMPLOYERS'LIABILITY y N D ANY PROPRIETORIPARTNERIEXECUTIVE NIA VTC2KUB 9203A71A-13 9/ 1/2013 9/1/2014 E.L. OFFICERNIEMSEREXCLUDED? N bele* Evidence of Insurance E.L. DISEASE -EA EMPLOYE F,L, DISEASE- POLICY LIMIT Remarke Sehedula, If more speed 2,000,000 1,000,000 1,000,000 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Col1:4197604 Tp1:1694012 Cert. -20287680 ®1988-2010ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ....................... This certifies that has permission for gas installation. in the buildings of .... ....................... at ..0.0.9... G ........... North Andover, Mass. Fed' .4- CXR.. Lic. No.. 43 6.. ..... A4 L GASINSPECTOR Check # I (, I 6 ist 2 .0 �Y •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I� CITY :'120 MA DATE PERMIT # JOBSITE ADDRESS o /L _ OWNER'S NAME GOWNER ADDRESS TEL_ ` TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL I RESIDENTIAL ®i CLEARLY NEW: [3 RENOVATION: 1 REPLACEMENT: F—D?' PLANS SUBMITTED: YES NOE] APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i 1 BOOSTER CONVERSION BURNER) COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER .� ..I -1 . f - f -J Ll- ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES B10 01 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ET", OTHER TYPE INDEMNITY 0 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 Q SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are tr an accurate to the est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co i, nn(all ertine t proA on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTERNRME ^?.�� LICENSE 03(, SIGNA URE MP E]MGF M JP 0 JGF LPGI CORPORATION [R# [ j PARTNERSHIPD(#= LLC 01#= COMPANY NAME: ADDRESS_- -------- -___----.---------________� CITY (j� r��_C� STATEP=JZIP (TEL =7_1_?..._"w FAX -- C � 4— EMAIL - -- ---..,.- ___._.. _-Z.� � N H � °z � o \ H H U W Pr `` W a z� c NFJ W � W 44 co w 5 CO a O w w w Q CO) W d orA a a a U J H a CL Q L w z w M W H °z z 0 H U W Pi C7 C7 °a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 y swww mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lestibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. A i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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 # or Self -ins. Lic. #: Job Site Expiration Date: 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia N° 9663 Date. k1'►3.70-:.. TOWN OF NORTH ANDOVER .a PERMIT FOR PLUMBING This certifies that ...:G.- ...�.� e tn� �M E' ............ . has permission to perform Sz? ........ plumbing in the buildings of .................. at . a �. c1 ... �? 7C."er'!.................... ................. . North An over Mass. Fee .?� - uo... Lic. No.. ...... ....... 2 %: PLUMBING INSPECTOR Check # 13 61 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 11 PERMIT# CITY_' dQ�/�-��V _( MA DATE ll v- JOBSITE ADDRESS %t)_ _, _ G /1..e e- K,/ OWNER'S NAME[Jed POWNER ADDRESS Yt-f!`t-e I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: LEI' PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ _ i —i= .__ .__{ I __ _..__ _--I __.._ ._! -._I :==== CROSS CONNECTION DEVICE �,l DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM a_! ._-_. i _ �i , I L .. ! I _ ,__._.., DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ! _ i _ ___..._I ._...I F DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN..... _( .__....' - INTERCEPTOR INTERIOR! -. _-_i -..._ _i ...._._-f .-._.__.! m._=i KITCHEN SINK ___._-_I .....-_i __ ___.! _-.__i .__.__ I -_.__ _i .._.-.___i ___ __I _ Al LAVATORY I _._...-__l ....__.._I ..._--( ROOF DRAIN _._._ __I F -j _-._ SHOWER STALL SERVICE/MOP SINK TOILET .__ I _ .._! _ URINAL - ni _ '' L._ a WASHING MACHINE CONNECTION ' ! WATER HEATER ALL TYPES WATER PIPING OTHER , INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES "NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND .. I 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 JE] SIGNATURE OF OWNER OR AGENT E hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the 4est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pli ce with al ertine provi on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEJ,_l/IGyL �!!` _ . _y _.. i LICENSE#[5C41GNATURE MP I JP [I CORPORATION .. # 3�PARTNERSHIPO#LLC D(# COMPANY NAME_ �(, y� , ".r`c _ _ ADDRESS CITY U. ✓t +. STATE ZIP y yS TEL 7-6 F6 " F' --J-0 FAX EMAIL Y O z 0 F n U \' W a w \ 1 o rl z z �rl o � H a W o u W z p a w a co LU LU co p z a a � w a U :1 IL CL U) w EE w I-- u. W H O C H U a rA z a a a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 'V www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ElI am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance reouired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation p 1 co ii y 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. lContraetors 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 %reformation. insurance Company Name: ?olicy # or Self -ins. Lic. #: 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 imposition of criminal penalties of a ine 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 ,f 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 certify under the pains and penalties of perjury that the information provided above is true and correct. i2nature: Date Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined 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 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia (' r Location 2d IL� No. `% Date 61 TOWN OF NORTH ANDOVER Certificate of Occupancy $ ing/Frame Permit Fee $ ;�j -Fund 'on Permit Fee $ A7' ermit Fee $ 1 2, wr Connection Fee $ �— �A% �A Waler Connection Fee $ TOTAL $ -� 353 wilding Inspector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 'SAGE 1 MAP +40. LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK 'PAGE ZONE SUB DIV. LOT NO. (� LOCATION PURPOSE OF BUILDING r OWNER'S NAME f • NO. OF STORIES IZE OWNER'S ADDRESS •{ O d- BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME YC o r , 1 do SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS i - t2 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED ���g� FEE PERMIT GRANTED OWNER TEL. CONTR. TEL. # 254A -L- e CONTR. LIC. # ©�_ S �SYrp 7 1-fff 7.L, g I it, 0-tt t 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST S'.1 Q tl EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSFECTOR BUILDING RECORD I OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL K. BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 EASEMENT AREA FULL 1/1 1/7 1/1 FIN. B M'T' AREA FIN. ATTIC AREA _ _ N_O 8 M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 �_ {I_ _ J_ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING CONCRETE EARTH HARD"V D COMMCN VERT. SIDING STUCCO ON MASONRY _ ASPH. TILE STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME _ ATTIC STRS. 8 FLOOR I_ CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE IF BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 8 COLS. STEAM STEEL BMS. 8 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ 1:r 13rd I ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. u ..Jw tr • ...... � 0 OFFiCF-S OR. 0 �► w Town of APPEALS ::.-" NORTH ANDOVER BUILDING C ONSLI2VATION J DIVISION OF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIREC'T'OR 120 Main Street North Andover. M.1SS.1c'huSC11S o 1 M4!`i (6 17) GH i•477 i In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number ! 9Z is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S 150A. The debris will be disposed of in: -5�q V (Location of Facility) S$ nature of Pern it Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. d" alb ON r•-1 0 z s•. x a x o O w E N v cn O � z A d aco o O w 50 O r� G U cz w" GG O U p w C X. a O W w W 00 p cs: y cn G w" O U O rs: —co w" W A a w v a co o z v cn v Q -14 cn uj om .. o a 2 H COD W f= C: W C.3 _a DEQ aG) L y m m O C yQ Vloe Z 0 CL. o Vl my0„~ MR m = =0:!-: _ cc _'o c v� 9 ch O.0= = m50.o .0 .@-. 06*.. co ::i L. coM fA i y C O m O) C m 0 CD c N CD s 0 Z O O 0 0 .v O O co O Z O co Z Q O CO) CO 0 I O C O•— y ME O.- a O O •E m m CD 0 CD o °cs O i !d O Q CL CM< o CID C.3 J-0 .0O2 Z ci CL V h cc CO2 is J Z LL i 0� cc W a cc Z F- C:) W Q > Q W W to > z 0 0 c 'u Location No. Date ' TOWN OF NORTH ANDOVER roL * Certificate of Occupancy $ Building/Frame Permit Fee $ orb" ,SSACNUs Fpur�4tion Permit Fee $ r ��P,rtlit(F�e' $ ,� Sewer Con e6 $ ~� Water Connection Fee $ 993 Building Inspector Div. Public Works PER::irr N„P. �.�� APPLICATION FOR PERMIT TO BUILD —NORTH ANDOVER, MASS. (/PAGE 1 MAP 4.40. LOT NO. 12 RECORD OF OWNERSHIP IDATE BOOK :PAGE ZONE SUB DIV. LOT NO. LOCATIONOff,- PQlllwNQ&_BUILDING 1 7' OWNER'S NAME L NO. OF STORIES SIZE OWNER'S ADDRESS �/, �.� ji BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME j /I C c— ,! SPAN _-- DISTANCE TO NEAREST BUILDIN DIMENSIONS OF SILLS - " POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES — SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION ?� LAND COST SEE BOTH SIDES / EBT. BLDG. COPT 7f ©Q PAGE 1 FILL OUT SECTIONS 1 - 3 (J EST. BLDG. COST PER Q. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED t� ' e� SIGNATURE OF OWNER Old -fHORIZED AGENT FEE PERMIT GRANTED — 44 0 19 OWNER TEL. # CONTR. TEL. #-3-2-3L B. 'e'l' CONTR. LIC. 11-4- 4 xreA 3 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING RECORD 1 OCCUPANCY 12 _ SINGLE FAMILY S'ORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL K. BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA '/. 1/2 1/1 FIN, ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I g FLOORS CLAPBOARDS 8 1 2 �_ _ 3 _ DROP SIDING WOOD SHINGLES CONCRETE EARTH HARDW'D COMMON ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME CONC. OR CINDER BLK. ATTIC STRS. d FLOOR _ WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I�POOR 1_ ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE AMBQEL HIP BATH Q FIX.) MANSARD TOILET RM. (2 FIX.) FG SHED WATER CLOSET — ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL B'M'T 2nd _ 1st 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. c . Haverhill Malden Framingham Brockton, MA (5081373-1886.(6171322-7160 (508)B72-6068 15881588-1171 VALLEY PREMIUM ,d b Quincy. MA Nashua, NH Portsmouth, NH INSTALLED BY FACTORYtTRAINi wlrtoow a nolrw IMfJ (617) 479-1211 160311!80-1510 (6031436-7548 I ; !` 5y* 1 AL TOLL FREE 1-800-3T0-1886`,' MASS REGISTRATION 1110079 2 RATION DATE _::moi_ / / / --SOURCE Q- CONSULTAh• HOME TEL O'ot 6�Sf7-8'71/ WORK TEL. AMR./RS. THIS AGREEMENT, made and entered into betweenXA�LEY WINDOW & SIDING, 50 White Street, Hairerhlll, MA:I , referred to as a contractor AND • �'` if- r V Z Ct J ;Fp ,. 1,+ '^ n/� r, �ta�o9 G?'/rt3t°,✓] SLf'�n- STATE ZIP-,.:-. ADDRESS/STREE7 if ClCI {ft R r�lv:,.,, '. ; .f. • ' i i ! i I ' . i - � .It a�;� fit w; 31 hereafter referred to as owner. ,I THE SAID. CONTRACTOR hereby agrees that it will furnish all labor and materials necessary. to Install the ollowing:de d�9 n �n �� � <I Irl l!`;. ► I ;..rt".,�a .t� premises located at. JOB ADDRESS CONTRACTOR agtees to start described work on/or about s o wee s fter final fittings and complete .,i�h., in about working days.'' DELAYED INSTALLATIONS: DO NOT START INSTALLATION BEFORE CONTRACTOR shall not be held liable for delays due to causes beyond control. The following work includes all labor and materials needed to complete your job in a workmanlll AA 'e I Instruct�ion^s:, ►1 Ff (J Area to be sided ! _/ IrJodE� / 1J n� S1_d t- Insulation to; be,used W ! Vr'e�Size i_N A—toVyr'e_ s. Siding Brand�►:-?s�'-�s- •::;: i— tells F �e Siding J -Channel ' Color Corner Post' Color ,,G,��11�4 4A r, Trim Coil tz 'Aluminum' ❑ P.V.C. 1 Trim ColoSrllmo l21 f�C"i_� 1 ofl X AAA - wiI7 Fascia treatmentNN// —_ Cd i r �i'y 1tt'ili"r�{ Soffit treatment Q� 11100 K NOT TO BE PERF M wtnrtnt�lttPAAtn7Arltl _L[% . 4 �'� a� .:il Door treatm6h I F` a>., _ 7— W- brand' Amt. Color _ i r Color ---- --- r as Gutter Style. Customer Initials i� ' Pipe Style Color TOTAL INVtSTME_Nt ` Color White ;DEPOSIT $ �{ E -Z Blocks Amt. 3 s' Amt. Color BALANCE due on COlitplellon $ "� Dryer Vents White �.��� :,s•Q'!of?�`-t,�r',�r� ' Gable�VentsSize -N/ Color �� 1., t N". c OWNER SHALL PAY FOR THE WORK i. Ifi:Cash or Check upon Completion ❑ Valley Will Make Bank Arfen6d1An B $ank'Modernization Loan ❑ Owner Will Make Bang Atrah b e ` 4 You. itlay cAtiCel this agreement tf It has been signed by a party thereto at a pla�oi3 btH�{ilhAti.itie edbtilY`fJi� * , which'ma)i fie hla"main ofilce-or branch thereto; provided you notify the seller 1rl�t 01111 rit111i' I�"6 N a ordlnary"`rn it"Oobilled by telegram sent, or by dellvery, not later than midnight of'tlie Ird.bu�litie { signing of thfs��giiili ant: See the attached notice of cancellation' form for en explaiia i'�rl'of thhi H� , ".i ? All material le Quarenleed to. be as specified. All work to be completed in a b c , workmanlikd ffidf ibr'according to Standard practices. Any alterations or, estimate ] I deviation frointIX&'specifications Involving extra cost will be executed only upon Authorized Signature ` written 0rde01and'4vi11 become an extra charge over and above the estimate. Ali agreements Contlfigent upon strikes, accidents or delays heyond our control. DATE " owner to aariy fire; torpedo and other necessary insurance. Our workers are fully NOTE. This proposal may be Athilrewn covered by Workmai n s Compensation Insurance. by al .'v: ,... -,x.�-„>..-,. Iii i'' • € An interest. charge: of; 1'/z% per month (18% per year) will be oat. I n�cen ave I„ i B added to any amount unpaid after 30 days from Invoice date. sktnalum o ` In the event of dner lAult in payment of this ordor any earl 1herrol anti the. arcouni is relmmd to �Z in AllMney ser cnite.rpnn, 1t,r niirrhe-.4t P(t, n< 1n ,p•u e.••y N.- :,k,nrllpn 1 r i .�.... - - __...--.FOLD ALONG UNE ��.. W \ oG N 012ci o N;; Go 1A i s..} . Z W- .. W f uT ae J r� `` W N r J W7 Ny W , 0 a 2caJ. i . A C J p. o .- OZV4 } W 3 CA Il! %ft W04= k HV, j ISO O W M 0 - - Yom. 6 W O .. � 1 Wei -I- Wool - QV VLL m .= OQ Yi�WZZO �UFW ' r �, •� • m . U. _ o► t 1.G O Z O Q � V- e s on aM 40 8 iLU 0 y aR R S S Q L, ti Q2 W p ' ;E• L Q N QL NOO OOftx CAA :ti O ' Y ` Cl• � Oj** • m cqw r= �N ci `o z3 = go m O cm zip cc = C N y R C E m �v - y Ocm m os c c :o O a c ._ o m CC3 C9•FZ O C LOO Of CL • C F� � y' O C •C :.'y mom~ O LCA W co .� M LL v, mRRc O Z © ? W E° ���•y� p y C3 O. C7 O lio O y CL O:fl N p CO p O.y=.. m i co O E co i O O v Z CD Q O CO) 0 C O Om CDi O G _ y O O �r= m m co CD CD 3� 0CD 0 cm o a CL cmQ N2 -p o Cc vCJ J� CL O O O Z co CL V C CcC C cc CO) CC W cc: Z Z O W } W U U 0 v a +' U) ►-� G v w O � a t O G a O p G z w W x ° cn o 8 cn y aR R S S Q L, ti Q2 W p ' ;E• L Q N QL NOO OOftx CAA :ti O ' Y ` Cl• � Oj** • m cqw r= �N ci `o z3 = go m O cm zip cc = C N y R C E m �v - y Ocm m os c c :o O a c ._ o m CC3 C9•FZ O C LOO Of CL • C F� � y' O C •C :.'y mom~ O LCA W co .� M LL v, mRRc O Z © ? W E° ���•y� p y C3 O. C7 O lio O y CL O:fl N p CO p O.y=.. m i co O E co i O O v Z CD Q O CO) 0 C O Om CDi O G _ y O O �r= m m co CD CD 3� 0CD 0 cm o a CL cmQ N2 -p o Cc vCJ J� CL O O O Z co CL V C CcC C cc CO) CC W cc: Z Z O W } W U U 0 OFFICES OF: APPEALS BUILDING ING CONSL11VA'110N HEALTH PLANNING r "awry 0 Town of NORTH ANDOVER DIVISION (W PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR 120 Main Street - North North Alidovcr. NI SS.t(IMSC115 () IH4 i (61 i) GHS -4775 In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number a --� is that the dcbris resulting from this work shall be disposal of in a properly licensed 150A. solid waste disposal facility as dcGncd by MGL c 111, S ' The dcbris will be disposal of in: (Location of Facility) Signature of Permit Applicant C"-/ 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.