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Miscellaneous - 21 CHAPIN ROAD 4/30/2018
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:_'�/'' Date Received Date Issued: / MPORTANT: Applicant must complete all items on this page -LOCATION !� Prin - • 'PROPERTY O.WNER Print 100 Year,0ld Strucfure yes no: wo]NO: �.:PARCEA/ ZONING DISTRICT, Historic District ye no t - - Village ye no Mach`ine,S. p ` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic .0�Well • D Floodplain ❑ Wetlands: - Watershed District •: - - ❑ Water /Sewer s ` DESCRIPTION OF WORK TO BE FFKI-UKIVILU: Identification Please Type or Print Clearly) OWNER: Name: Phone: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BOLDING PERMIT: $92.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ %�—e FEE: $ qT51 r� Check No.:Receipt No.:— 121b NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund !Sgnature`bf Agent/Ovvner Signature of contractor Plnnc Ci jhmittarJ n Plan-1NaivPri I -I Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ Plans Waived❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ .. Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _ Planning Board Decision: Comm servation Decision: Comments Water & Seger Connection ermit DPW To`vz ]Engineer: Signature: Located 384 Osgood Street FIRE DEPARTitfVt-wt =Temp Dumpster on site yes no Located at 124 Main Street Fire Departinerit sigiiature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166Section21A-F and G min.$10041000 fine Doc -Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriatepermit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building 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 Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ 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 NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ 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 app> al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Peanit Revised 2012 Location 2— Po No. Z ,. Date l 1 s�-yI•. TOWN OF NORTH ANDOVER Certificate of Occupancy Buildin g/Frame Permit Fee Foundation Permit $ $d (b Fee Other Permit Fee TOTAL Check Check # i f Building Inspector 13 N ir-A 1 00 N N O LL LLI m t u \ "a 0 LL u 0-C l%j Z Z > m O "O LL L 00to K C U LL ? Z > d L w C LL O CA Z U LU L bA = K ej N C LL oc O CAtJJ L 00 K C LL z a LL N m O Z a+ W v N 4-; v 'Y O N 0o O V_ yr •�L CL a+ CD Q - o CN v GCL L CD N J7 0 ECD _ _cc �N �0— J� yCc J �_ Z: �cc L (�� • 0 • •= as C tm N �• O o o = �-' N Q -E c 0 -b C Z .s .tn00 _ M3 c > H L QCL0) 0 CD 0 _ •(A N 0 = Q L L 0 =a CD F- N O V m ujIL •� d y C W E v v n 0-0 cc mco 0 > Fc W •O oCL 0 = Z FM • N �E w N W y 0) 19W W I% W The Commonwealth of Massachusetts Department of Industrial Accidents IlaOffice of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organi'zatiorAndividual):, Address: 7 `(i/>2 % J/ 7� � baa City/Stale/Zip: ���� ,�/% D / ��' Phone #: � %� y • . Areyou an employer? Checkxhe appropriate box: 1. [ I am a employer with 4. ❑ I am a general contractor and I Typo of project (required): 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• [1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. El Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.] t employees. [No workers' 1311 Other comp. insurance required.] *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they ire 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:_�/�i�C�•� Policy # or Self -ins. Lic. Expiration Date: F--d4F'/ Job Site Address: City/State/Zip: Attach a copy of the workers' compensation pollcy 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 certio un*r the pains and penalties ofperjury that the information provided above is true and correct. Si afire: Date: r Phone #• Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 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 retained 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 GomMonwealth ofMassachuseutts Department offadustrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 TO. # 61.7-727,4900 ext 406 or 1-877�,MASS.AFE Revised 5-26-05 FaY,# 617-727-7749 VAVMmace an-uhl n I EIN # 51-050-3313 MA Reg. HIC # 149221 'r MA Lic. UCS # 78130 BBB, ( Single -Ply License# 1711 Name: V TG. ambes MCofing SGvLCPiZ932 CO. 265 Winter Street Haverhill MA 01830 —Licensed Insured Factory Trained iz� -,3011014 16511 :Factory Certified Haverhill MA 978.374.9224 Lawrence MA 978.687.7339 Hampton NH 603.929.9224 Hampstead NH 603.329.8200 Toll Free 1.888.SOS.ROOF Telephony - t Alt. Telephone: Email: _ 7 Billing Address 7 ,, ;'.^ 12 c City:65r Anl-)[:Ik/" State: ilk. Job Address: City: State: Scope of Work Strip and Re -roof ❑ Re -roof Approximate Roof Area: ❑ Prepare for re -roofing by ensuring all safety measures in accordance with OSHA standard regulations and landscape is properly protected. ❑ Remove existing layers of shingles down to roof deck and dispose of in a legal fashion from the Job site. ❑ Inspect wood deck, if we discover any rotted wood, replacement will will performed at *$ per LF for roof deck boards. If substantial deck rot is discovered, re -sheathing of roof deck can be performed at *$ t , 2. t) per SF. If individual sheets are found to be rotted/or de -laminated, removal, disposal and replacement will be performed at *$ per sheet. If any trim boards are rotted, replacement will be performed at *$_� per LF for new pre -primed pine. Inspect siding at roof line and all flashing behind siding, if we discover any damaged flashing or siding at the roof line, replacement will be performed at *$l i ; . If wood deck, siding, and flashing is sound, we will re -nail any loose wood to rafters, sweep deck, and prepare for roofing. 11 Install Install 8" drip edge to all rakes and eaves. Color \,T/ f'' s ❑ Apply ice & water shield (UNDERLAYMENT) as per manufacturers' specifications and/or ' F ❑ Apply premium (UNDERLAYMENT) to the balance of the exposed wood deck. ❑ Re -flash all plumbing stack pipes, and any roof penetrations as required and dictated by good roof practice to ensu! waw tightness. ❑ If upon inspection, we discover chimney lead to be worn or deteriorated replacement will be performed at *$ a - C Install a new: Year ❑ Traditional Architectural ❑ Designer Color i't ;6AC V'l ❑ Furnish and Install a new shingle over style ridge vent system ❑ Soffit vent system *$ ❑ All debris generated by Lambert Roofing Co., Inc. will be cleaned up and disposed of from the job site in a legal fashion. Under no circumstances will the watertight integrity of the building be compromised. / Special Notes ,SA ,—,,r, As ,—,,r >.ia ,' r Vis; f �r / �. - ftra n a� rt- `1 -e .vv a_ ^. 11 .�v a•�'.. , Z % . to ie?. _ _ ., r-. n i.v 1� t,.. r. ,`r G. A, . .� t r P r"i, !a''. r'1 M_ n'S' ' �A. .-.�1r' �,/4r-:. t l UPON COMPLETION AND PAYMENT IN FULL, ROOF SHALL HAVE A WORKMANSHIP GUARANTEE FOR A PERIOD OF_t) YEARS HONORED AND ISSUED BY THE LAMBERT ROOFING COMPANY AND 1�5 YEARS HONORED AND ISSUED BY THE SHINGLE MANUFACTURER. ❑ MANUFACTURER UPGRADE *$ *Denotes potential additional costs above the total estimated price. TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE r-7 C°/' The Contractor agrees to perform the work, furnish the materials and labor specified above for the total sum of: $ Ar (*) Payment will be made according to the following work schedule: $ deposit upon signing contract t ,� J $ by _/_/_ or upon completion of upon completion of contract. (Law forbids demanding full payment until contract is completed to both party's satisfaction) You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram or by delivery, not later than midnight of the third business day following the signing of this agreement. See attached notice of cancellation for for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ANY BLANK SPACES Q , Acceptance of the Contract Proposal Home Owner(s)Signature(s): --�"� Date: ! I. Si g (s) Contractor's Signature: �R Date: aanl ertroo I<ne.Com (Please see reverse side) CERTtF1CA,rr__.* =01ATE Dlyyyy) 117Y INSURANCE 08/28/2013 1 CERTIFICATE IS ISSUED AS A MA' TER CY-' '"N0N7EPO R'GHTS UPON THE CERTIFICA'E HOLDER. THIS JIFICATE DOES NOT AFFIRMATIVELY OF 'qEGA"Nr7 .1 -1":0, 4O, CS NO OR AL! ER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OrF INS )RANCE 11GE"' NOT XNS 1: 1`61 : A COY"RACTE-TINEEN THE ISSUING INSURER(S), AUTHORIZED i REPRESENTATIVE OR PRODUCER. AND THE CERTiFICATE ii0t.DER, t ----------- 1APOR TANT: if the certificate iwider is crit WDETFK_mAL TR7 e—ndorsed. K SUBROGATION IS WAIVED, subject to i ',he Iterms and conditions of the policy, certain pojicies mpy e.,dorser:rlent. A stateme' f -t an nt on tris certificate does not confer rights to the C tificate holder in lieu of such endorsement(s). TN GENCY INC SURANCE A 1/2 Jefferson A-,,-cnue 2nd r,Lc)c�r BOX 5iJ, CdA- 0:19,11,11- 0 5.11 Jezrold Kameras )_7 4 5 - 5 9 0 5 1 FAX 197S) 745-5493 a -al zs uranc e. Colic �I_AFFI,R SPJCI C.'VERA E NAIC a *URE R A kt Lr6t M(rzury lasurance Co �sum-RE:Safety lusurance Cor—a CERTIFICATE HOLDER ANCELI-14TION Lambert Roofing Co. S�MLD ANY OF 114E .418OVE, DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPff2ATI0M CATL THEREOF, NOTICE WILL BE DELIVERED IN 2t5 'r,7inter Street Haverhill ACCORD 25 (2010,1051, liM 01:3.:0 - Tyle 13.:0- '14e AC'0f,'V rnme 14 J�LvAiri HE. ?UL ICY PROVISIONS. FiF.51RESE Mil TWE 4� (!'l 1998-2010 ACORD GCIRPORATION, All right. reserved. C.f. -I".' railstsr..,,d marl -u'. of WCORD T�a--Tibert :%'-_WZERC.Charti 3 I nsurance ccimrl,�Ry Roof ng Corqjany — --------- 51000,000 -ISLJRER D Ace Am ezican insurance Co. 2t-3' Winter Street 1-_.NSU,RER;:.Ac,e Amer ican7r�surance Co L 01830- AG,:REGATE i. 5,000,000 DED 2 4 0 I i ElENT!0N.-K QVERAGES CER TIFZfTF N6MBER: REVISION NUMBER: : -S!, ' TO CERTIFY !.HAT THE POLICIES ()� INSURANIC; I IS E:., 1J, 0:f' 8E:PN TO THE INSURED NAMED ABOVE FOP THE POLICY PERIOD ED. NOTVATHSIANIDING ANY F;E0J:R.6 1EN11 I OR ol_,R 1r:1CATE NiA,.Y 4y CJMTRAG1 OR OTHER DOCUMENT Vf.-TH RESPECT TO WHICH THIS I SE ISSUED OR MAY PERTA.N, 11. Xr'1_USk-'NS -L 1: JI F'iE POLICIES i_�ES..RISED HEREI-N 113 SU E T TO AII. Tl E T RM_ 91 AND CONDITIONS OF SUCH OCL S. L V, ITS Cl IVE r�'11-NIREPUCM BY Pk,U "LAiMS TYPE OF INSURANCE J6 F------------- T 7� i7N5U1yE_XP UABILITY tdA9taIor, i n Nw. 1, F 1 ------ LIMITS L 3 E AM i OCCURPE NCE 8 0 2 011 312 F_ ,--EN 'LRA'% ;.!.AR?t.IT-Y 11000,000 Y' C)F QPERATf0NS L 10 2 G E 501000 Clxuf�� 12 /11,0 1z, di Mi�, FXoF s.„'or �, 11000 1,000,000 1 PFR.ONAI_& A0V INJURY $ 11000,000 3EN'L AGGP;-GA-.,U Uim.1,' r,Iwqjj i), -l" GENEA, S 2,000,000 CC1!0,,?l0P AGG 2,000,000 Xj AIJTIDN7081LE toAS.R.Mf _v .5K O(L ANI —_ -_0 fRi?OILY AU7- "S !NiURY kp,,,r 6 2 1 U00iLY tNJIJM xQ A OPFFT_f AGE. CERTIFICATE HOLDER ANCELI-14TION Lambert Roofing Co. S�MLD ANY OF 114E .418OVE, DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPff2ATI0M CATL THEREOF, NOTICE WILL BE DELIVERED IN 2t5 'r,7inter Street Haverhill ACCORD 25 (2010,1051, liM 01:3.:0 - Tyle 13.:0- '14e AC'0f,'V rnme 14 J�LvAiri HE. ?UL ICY PROVISIONS. FiF.51RESE Mil TWE 4� (!'l 1998-2010 ACORD GCIRPORATION, All right. reserved. C.f. -I".' railstsr..,,d marl -u'. of WCORD LIMBREi—ALIAS x I EXCESS L-14-23 �ACH 0ACIJRPeNCE 51000,000 X AG,:REGATE i. 5,000,000 DED 2 4 0 I i ElENT!0N.-K i VlORKEPS COMPENSATION AND EMPLOYERS'LIABiLITY 1, KI _ROPPI� 4-W� T �__2PIPAR 7,N_�RlEXIE-CUT IV IN JI tdA9taIor, i n Nw. 1, F 1 8 2a :6". F.,2 0 L 3 ii 8 0 2 011 312 F_ EA EMPLOYE EI ------- 11000,000 Y' C)F QPERATf0NS L 10 2 G 1.4 DISEASE POLICY OMIT 1 000 000 workers comp & Emplouerg 1 1�iS,62-05in75-_' 1,000,000 Liability for NH 11000,000 CERTIFICATE HOLDER ANCELI-14TION Lambert Roofing Co. S�MLD ANY OF 114E .418OVE, DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPff2ATI0M CATL THEREOF, NOTICE WILL BE DELIVERED IN 2t5 'r,7inter Street Haverhill ACCORD 25 (2010,1051, liM 01:3.:0 - Tyle 13.:0- '14e AC'0f,'V rnme 14 J�LvAiri HE. ?UL ICY PROVISIONS. FiF.51RESE Mil TWE 4� (!'l 1998-2010 ACORD GCIRPORATION, All right. reserved. C.f. -I".' railstsr..,,d marl -u'. of WCORD 24i VYIYTFR Havei-hill M -1j, qjt,,--M Office 0-f Cons m." Affiairs and iusiness Regulation 10 i.11,,3za - Suite 5 170 h -us etts 0-2 '116 �J,:, IC ir cai. Contractor Re,- is tion trw Peqistration: 149221 Tvpe: Private Corporation Expiration. 1216/2013 Tr# 218746 I.t-,%L.R.0 dba Larnber"I Roofing ICF0f-1,4P(,fnY RICHARD LAMBERT 265 WINTER STREET HAVERHILL, NIA 0183C, Ur,date Address and return card. Mark reason for change. Address Renewal I Employment F Lost Car Employment 1 k, BUILDING -PERMIT TOWN OF NORTH ANDOVER APPLICATION F R PLAN EXAMINATION Permit NO: -,��� — -n Date Received - t a 0ORTfj TYPE OF IMPROVEMEN New Building Repair, replacement - Demolition N 2-.-0 PROPOSED USE Residential Non- Residential One family Two or more.family Industrial No. of units: Commercial Others: Assessory Bldg Other _ dl�=_}"��--a'�r�Y':1''':'�.�:Vi-'.'-�'�fa.��:=. ,-rs- .SYa "�eDS "•tM�m;���-.-s.�r:'-haw.:. a `..:.,-'..'s..���}.i..;r.a�t ie�5c4i-�.-?:.. �.u- ."f.'::i41.»1'��•;..;`�•f' .���'::t-�1]9F�lJo :•'�3/',�.�.iii•��-.M1t�r-r.t.`"a:yv t�1�-r/.s�.;o'. '. :~.-�:�rv'.�2,,1�1,;t,..1..;.: .�<-�.i-?.1,:.:i�t�a:.h� :��`"��..i,z�. �'ii�� .y. •.....1 ..._ .M._�-= :s.�l--R:��a'X'yT� _..=_, :� r.�.Y_ RIPTION OF TO BE PREFORMED: rpt✓ v f- G� �v t� 4 r—kor int► i'h �k e �S Ti�1 rit'�rr�T OWNER: Name: 474eation Please Type or Prim Clearly) ARCH 1 EC I /ENGINEER —� Phone: Addres No. FEE SCHEDULE: BULD/NG PERMIT; $12 00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ - .S2 BO FEE: $_� Check No.: NOTE: Persons contracting- )pith Receipt No.: unregistered contractors do not have acces to & - a ntv I..d Plans Submitted Plans Waived Certified Plot flan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Well Private (septic tank, etc. Tanning/MassageBody Art Tobacco Sales Permanent Dumpster on Site Swimming Pools Food Packaging/Sales THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - UFORM PLANNING &.DEVELOPMENT COMMENTS CONSERVATION Crell..U AEN TIS /y%(�" HEALTH COMMENTS Reviewed o DATE REJECTED DATE AP -PROVED - Reviewed on Si nature Zoning Board of Appeals. Variance, Petition No: . Zoning Decision/receipt submitted yes Planniri.r,. aoard Decision: Comments Conservation Decision: Water & Sewer Connection/Sic r -- DPW Town Engineer: Signature: Comments Dimension Number of Stories:Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10o-$1000 fine Doc -Building Permit Revised 2010 Building Department The following is' a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, interior Rehabilitation Permits ❑ Building 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 Addition Or..Decks ❑ Building Permit Application. ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.G. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of P!-oposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ IVI "'ass check- Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Construction (Single and Two Family) ❑ Building Permit Application ❑ Celltified Pr oposed PI of Plant ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract .0 Mass Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products DOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Ju all cases if a variance or special permit was required the Town Clerks office must sump the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at fine Rea stry of Deedsdi . One copy and proof of recorng must be submitted with the -building application Doc: Building Permit Revised 2008 m O z H ►�� A ov L2 cn O z w° a�4 U iz u. O Uw Z w�' i w O u U a W w�' aj U id w a0 in w W W 0-+ w G wQ o z cn Q o cn co -:= o c � " C +� �o C �o �v �a MIL Ilk*m o �• o u rn ei m C E �S U:mm a N co N tm m 5 Vi W o �k t C �N C �EC �moco y CLL3 L: CD = O Of C �Q,CZ � D m cj o H Z O C F- C Q i y m c o = o a�� ~ s CO) W •H CL ea C Z U `m oo®=c g CO) a m 'C 0:6 = R i H �� 10 H .c .4- CL= m a T 2 O 0 oc L C o s Z � d O CO) C C CM ca Cl h •� m m � 0 CD CLCD ++ 3� � � L CL �Q c Cal .6-9 c ccc CJ J •0 d C* 0 Ca. Z CD CD CL V v� C C C _cc C. CO2 D ul U) OC W LU LUW U) 0 ofric- e of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: -108511 Type: Expiration: 80912012 DBA SMITH CONSTRUC-1710 -N Kevin Smith 63 INGLEWOOD ST: N Andover, MA 01845: Undersecretary Massachusetts -'Department of Public S:Ifet% %wAfArd.-Of Building Regulations and Standar('Is Construction Supervisor License License: CS 102589 Restricted to: 00. KEVIN SMITH 63 INGLEWOOD STREET NORTH ANDOVER, MA 01845 Expiration: 3/5/2013 Tr#: 102589 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant lnfori Name (Business/Org Address: City/State/Zip: dual): e 1 $w" CA #: q 16 6 (3 7-7 06 Are you an employer? Check the appropriate b x: The Commonwealth of Massachusetts S Department oflndustrialAccidents have hired the sub -contractors Office of Investigations listed on the attached sheet. # 600 Washington Street r ;'w �' f Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant lnfori Name (Business/Org Address: City/State/Zip: dual): e 1 $w" CA #: q 16 6 (3 7-7 06 Are you an employer? Check the appropriate b x: I. El am a employer with 4. UI am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. YBuilding addition 10.❑ Electrical repairs or additions 11.0 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. t Homeowners who submit this affidavit indicating they are 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 acid 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. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance .coverage verification. I do hereby certib under dApain anc enalties of perjury that the information provided above is true and correct.' VAI+ Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # zG/ 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 -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 confinnation 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 pen -nit 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 surd 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 pen-nit/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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen -nit 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 Fax # 617-727-7749 Revised 5-26-05 wwvv.mass.govldia 4 S�ban,�naz�s , 7 'V,OwmA),j J��� S,g-fes, % Al 10 i© 1 -4 Ml z til 44 UA -r -d 74V s, d . PO vovvco /43gtl o /o �, i✓Tfi�.�.2._ Ca. Yy i90 1,�. -:0 i wc3zo26.�s y - Ll I — — J 0 \ n \ � \ "00 25 � Z Cleoo R a w x o ZONING INFORMATION: ZONING DISTRICT : R4 MIN. BLDG. SETBACKS: FRONT 30 FEET SIDE 15 FEET REAR 30 FEET ASSESSOR INFORMATION: MAP 20 PARCEL 13 DEED REFERENCE: BOOK: 94 PAGE: 93 OWNER INFORMATION: RALPH & BARBARA FINCK 21 CHAPIN ROAD NORTH ANDOVER, MA 01845 52.94' LOT AREA 6,884 S.F.f 41.6, PROP. STEPS \ 37.6' PROP. 5' X 5' PLATFORM 12 1 PROP. PORCH EX. 2 STORY WOOD FRAME STRUCTURE ROOFED -,----*If -T ENTRY 21.8' 25.1' R=280.00' + �= 79.00' CHAP/N ROAD I CERTIFY THAT THE STRUCTURES SHOWN WERE LOCATED BY AN INSTRUMENT SURVEY AND EXIST ON THE GROUND AS SHOWN. 13.4' 'ROPOSED -13.4' rn EXISTING PLOT PLAN OF LAND #21 CHAP/N ROAD NORTH ANDOVER, MASS PREPARED BY: JOHN D. SULLIVAN III, P.E. 22 MOUNT VERNON ROAD BOXFORD, MA 01921 (978) 352-7871 SCALE: 1"=20' DATE: 7/29/10 7 Date TOWN OF NORTH ANDOVER PERMIT FOR PLk1NIBING This certifies that ... .....Allel :'l 4!( ............ has permission to perform ..... .... .............. plumbing in the buildings of .... ...!,.C..,9...................... at ..._: .....P t h....J�J........... North An overt,,, 4ass. F > . .. rQti.. Lic. No.,.2. 0.� . . PLUMBING INSPECTOR Check # f MASSACRUSETTS UNIFORM APPLICATION POR PERMIT TO )D O PLUMBING (Typ e or print) j 6/� /�j NOP,TaAND OVER, MA,SSACHUSETI Date 17 Owners Name � 4 i i %G Pent BuildingLocatidn Amount ----------- Type ofOccu azicy ' Plan Check Submitted ices � No Neto Renovation Replacement Check one. {SGA LAIJ VRL4 (Print- Or typo) G� Corp. Installing Company Name Partner. Address � EimnlCo. _- Business Telephone �'j — 7 7 - TIame of. Licensedl'Iumber: �! 0> ( � Insurance Coverage: Indicate the e of insurance box: coverage by checking the appropriate Bond Liability insurance pokicy Other iyp e of indemnify. ;Insurance �7aiver: T, the undersigned, have been made aware thatthe licensee of this application does not have any one ofthe above three insurance _ - - Owner � Agent El ,gnature ve ap_ I hereby certifythat all Of the details and informationl b per fttpd oot ed nude Pred) in abo tIssued forIbis applic ti nw"zmll be in best of rnyla,owledge and that all plumbing wLa d installationsp e Cha ter 7.42 of the General Laws. compliance with all. pertinentpmvisionsoftheachus tafePl in p r By: a ,cells um or Ty^p�eofl'lum ,ng License Title © Master Journeyman Cityffi vm ,cense um e .APPROVED (OFFICE USE ONLY - _ J"ob Site Address: City/Sfiate/Zig: Attach a copy -of the workers' compensation policy declaration page (shavdmg the policy ttumber.and expiration date. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of c 'minaT penalties of a nue up to $1,500.00 and/or ane year imprisonment, as well as civil penalties in the form Of a STOP WORK ORDER and a sine Of up to X250:00 a day against the violator. Be advised that a copy of Ibis statement inky be forwarded to :the Office of Investigations of the DLA, for insurance coverage verification, _ I r% hereby cernfyp under thepains andpai alfies ofper, jure thczt the znformarionprovided above'is true and correct SiQuaiure: _ Phone:#: Dfftcial use only Do not write zn ilzzs area, to be completed by cite or town official _ City or 'l_ O VM: ..1'ermMUcense fssTi Authority (circle one1; X. Board of Health 2. Buiiaing Department 3. Cify/Town Clerk. 6. Other Contact Person: 4. ElectdcaI Inspector S. Plumbing Inspector Phone 'he Commonwealth ofMassachusetts • - Depai�`ment. o f �r2dushzal�ccidents - f flfjzce of)Wpestigrxtin s 60.0 Mashinb..ton Streei .V0rSt0i2,0.21I1 Yn4w xresagowidia Workers' Compensaiionitnsurance AfficIa.-it: Bunders/Contractors/ E r-txxc ams/PIumbexs Dicant TriforxaatiOn ' Please Print Leazbl� Name (Business/Ora nizatiorillnd -vidual): Address: City/State/Zip: Phone #: ` . -Are you an employer? Check the anpropriate box' i. C[ I aaI a employerwifh 4. ❑ i am a a ' Type of project (required): , bezterai contractor and X employees (fill and/orpari-time) 2. ETI have hired the sub -contractors El NW, consiruciion am a sola proprietor or partner- listed on the attached sheet 7 Q R emodeiing ship and have no employees Thew su'f}contractozs have olition working for main any capacity, [NO Vvorkars' con . insurance •� workers' camp, insurance, J. ding addition ❑ We ars a COLpOr8.130n and Its - required.J 3. ❑ am a homeowner doing 'work officers have exercised their Ecafrepairs or additions -I all myself. [No workers' comp, right of er-empiion per MGL bing repairs or additions c. 15'2, § 1(4), and we have L irs,trance required.] f no empIoyees. [No •workers' repairs comp. insurance, required-] r at tht:Ecad—o beenr.• ��o �n -' ...g :Y=ir woL':�"S• aornr'n�` rr. tv1�n., u•••i.`LU��-Lr Homeowners who suomifiii9s affidavit indicating h , am a t cy cam_ sI1 and ,.ilea hirenutsi& non_rrzc+ors4Ysf rdknit a new affidavit indicating such. - 4C0Ilt[EG%Jr5thyi Cbt�fs^Lnr W'.'.a"°5...�"cCa'cd ct7 ad¢¢iil0II3.i Shect Shnw]II�'the: - o xiame'of the sub confracfors and thcirwork=' comp. policy infora ttm dam art employer that is providing ruarkers' cornperzsation insurance for trip employees .BeloH, is the potici) and job site. irtformdtaon., . Insurance Company Name: Policy # or Solt ins. Lin. #: Ex=piration Date: J"ob Site Address: City/Sfiate/Zig: Attach a copy -of the workers' compensation policy declaration page (shavdmg the policy ttumber.and expiration date. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of c 'minaT penalties of a nue up to $1,500.00 and/or ane year imprisonment, as well as civil penalties in the form Of a STOP WORK ORDER and a sine Of up to X250:00 a day against the violator. Be advised that a copy of Ibis statement inky be forwarded to :the Office of Investigations of the DLA, for insurance coverage verification, _ I r% hereby cernfyp under thepains andpai alfies ofper, jure thczt the znformarionprovided above'is true and correct SiQuaiure: _ Phone:#: Dfftcial use only Do not write zn ilzzs area, to be completed by cite or town official _ City or 'l_ O VM: ..1'ermMUcense fssTi Authority (circle one1; X. Board of Health 2. Buiiaing Department 3. Cify/Town Clerk. 6. Other Contact Person: 4. ElectdcaI Inspector S. Plumbing Inspector Phone 97b'i Date ..... /.1...— 17/- /O TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that............... .................................................. .... .............. has permission to perform ....... 13 f..../... ......... wiring in the building of ................:!..!///l..!/...................................... at ....... J..f .....t.,.. /..'L.%V ..... 2.0 ............. . Jjorth Andover, Mass. ELE iCAL INSPECTOR ~ Check # _�� &\- Commonwealth of Massachusetts Official Use Only RNIM0tri Mwe Department of Fire Services Permit No. G%1 kvi- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFOR11 TION) Date: City or Town of: To the Inspector of Wires: By this application the undersi ed gives not' e of his or her intention to perform the electrical work described below. Location (Street & Number) 9 Owner or Tenant 12.4 /, p14 JA Owner's AddressZ ,-164 F_ Telephone Is this permit in conjunction with a building permit? Yes SZ No ❑ BLDG PERMIT # Purpose of Building S, F 11a46rG Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: W i f r-/ �.. -- �S'/�%� /�Nl� .s �C.�iv l�odZc ff No. of Recessed Luminaires --••- •--•� •....�.......r..s No. of Ceil.-Susp. (Paddle) Fans I-- usuy uc wuc veu by the Jim ecior of wires. No. of Total - Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ o. o Emergency Lighting rnd. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches J No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. TotaTonsl No. of Alerting Devices No. of Waste Disposers uerTons !fTota�ls:* KW No.of Self-ContainedDetection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. Devices No. of Water Heaters' No. of No. of of or Equivalent Data Wiring: Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: 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 NEC 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 X BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: CQt T -/SIL LP NG LIC. NO.: ,4 %/ f&3 Licensee: Signature p LIC. NO.: ` �j 7 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: V �� le << Address: l PMOlj41Y Ptd, W1055 &1dfj/s`V&y IA �4��j�'f Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — Failed — ( ] Re -inspection required ($50.00) - [ ] Inspectors' comments: J� 1 12 - (Inspectors' Signature - no initials) Date 2. F SPE -10 Passed Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: �^ l (Inspectors' Signature - no initials) f�WDate 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts UVDepartment of Industrial.Acculents Office of Investigations 600 Washington Street Boston, MA 0211'1 www.massgov1dia Workers' Compensation Insurance .Affidavit: ]3uilders/Contractors/FIectricians/JP'Xumbers NaMa(B.usiness/Organization/Individual): V,, (f) () 6. W(! J (AI�"e_ a Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate bdx/ I.f I am a employer with._ 4. ❑ 1 am a general contractor and I employees ((full and/or part-time).*have hired the sub -contractors 2. ElI am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c.152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] j Type of project (required): 6. ❑ New construction. 7. ❑ Remodeling . 8. [] Demolition 9. ❑ Building addition 10,WElectrical repairs or additions 11. E] Plumbing repairs or additions 12. F1 Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. 1 T Homeoyiners who submit this affidavit indicating they are 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. lam an employer that isproviding workers' compensation insuranceformy employees. Below is thepolicy andjob site information. • Insurance Company Name: Policy # or Self -ins, Lic.#: c(�.0 . Expiration Date: e Job Site Address:C6 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 WORD ORDER and a fine of up to $250.00 a day against the violator. De advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby cify under the ains and nathat the infor adore pro vided above Zzivle and correct. A An Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitUcense # Issuing Authority (circle one): 1. Board ofHealth 2. Building Department 3. City/Town Clerk 4. EIectricaI Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: Md --- PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER. MASS., PAGE l MAP K-4O.� LOT NO. I 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE ZONE SUB DIV. LOT NO. �) LOCATION PURPOSE OF BUILDING I n OWNER'S NAME NO. OF STORIES I SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAM _ n (JYCX 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 MATEWAL 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 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 FILED1� �G SIGNATURE OF OWNER OMAUTHOALZGD.AGENT F E E� d `fes �y PERMIT GRANTED 19D 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PERI SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR OWNER TEL. # CONTR. TEL. # 49-J U 4� CONTR. LIC. # OtR &19'x` H.I.C.# 10-1312 < 1 OCCUPANCY RG -LE FAMILY STORIES _ ULTI. FAMILY OFFICES _ PARTMENTS CONSTRUCTION 2 FOUNDATION _ 8 INTERIOR FINISH DNCRETE _ 3 I 2 13 )NCRETE BL'K. PINE IICK OR STONE HARDW D ERS PLASTER _ _ _ _ DRY WALL UNFIN. 3 BASEMENT IEA FULL FIN. B'M'TAREA _ 1/2 1/1 FIN. ATTIC AREA B M'T FIRE PLACES _ AD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS .APBOARDS I ---i 1 2 3 IOP SIDING CONCRETE �_ OOD SHINGLES EARTH iPHALT SIDING HARDV✓'DiBESTOS SIDINGCOMMCN ' STUCCO ON FRAME BRICK ON M N BRICK ON FRAME CONC. OR CINDER STONE ON MASONI STONE ON FRAME -- F GABLE I HIP GAMBRELMAI FLAT I SHE ASPHALT SHINGLES WOOD SHINGES SLATE TAR & GRAVEL TT WIRING 10 PLUMBING BATH (3 FIX.) TOILET RM. (2 FIX.) NO PLUMBING STALL SHOWER MODERN FIXTURES z BUILDING RECORD 12 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. g FRAMING I 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 7 NO. OF ROOMS B'M'T 2nd _ 1st 13rd I GAS OIL ELECTRIC NO HEATING %n O Oz v aN T-4 a O C . C C H p C O '3 d91 W � O E< m m p CD N E S p m I � a� Cb p W ccc W or N 'O C4 C W : � H CD . A= C3 ccm p C d. O 'L W•�Z C O •` p I:LO CL o v Di m S •p it lZ c � moa ra cam= oa 4 IM m U) 0 LLO7 v J W w ON -611, P7 rftm p O L w z o, O y 0 C IO p� C CO) 'O O ff mm G3 O co O > 0 0 03 O a �Q 0cc, I� a..O.H O d V h O C•- •� C CV3 CL CO) 111 AM J. SCOTT Director y Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146M_aiz Street North Andover, Massachusetts 01845 In accordance with the provisions of MGL c40, S 54, a condition of Building Permit Number 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 i�li: (Location of Facility) signature of Permit Applicant NOTE: Demolition perry i from the Town �f North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NO 14 TOWN OF NORTH ANDOVER cF pT •. OOL A F--1 b PERMIT FOR GAS INSTALLATION p This certifies that ..%.:. ...............CN :?. . �• N has permission for gas installation ... // . ................ �. in the buildings of ... ............................ . at . %.! . r. ::�?!��.../.' ......... h Andover, Mass. Fee.,, !/ Lic. No. .:... .......... .. ....... GASINSPECT WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or T pe) �JY ) V �� , Mass. Date 10 1 g � Permit # Building Location —Q I 1r) Owner's Name 1 �nr— Type of Occupancy (A Ill New ❑ Re10 novation E Replacement E Plans Submitted: YesE o E Installing Company Name AYOTTE PLUMBING - HEATING Address & AIR CONDITIONING _- P.O. Box 218 Business T Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation El Partnership Er Firm/Co. Certificate # INSURANCE COV E: I have a curve bllfty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please Indicat the type coverage by checking the appropriate box. Atllabllfty Insurance poll Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permft application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in ab a application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the Permlt Iss ed for this application a In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gqnq6al Laws. By T e cense: mber ignature o ce um a or as Etter Title ilror »� Master Ucenso Number ' '" City/Town Journeyman W11X7vF f) - C _ , O IN MON■ .. ■NNNNNNINNNN■ MONSOON mom 1w4HIM2190 9. 0 mono MEMO .. ■i®■®�����®®��������«NOUN •• ■o���r��■■.���■ ■o■ ■m■ ■�� 0 ONE •• ■�������������������■ NON■ Installing Company Name AYOTTE PLUMBING - HEATING Address & AIR CONDITIONING _- P.O. Box 218 Business T Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation El Partnership Er Firm/Co. Certificate # INSURANCE COV E: I have a curve bllfty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please Indicat the type coverage by checking the appropriate box. Atllabllfty Insurance poll Other type of Indemnity ❑ Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permft application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in ab a application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the Permlt Iss ed for this application a In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gqnq6al Laws. By T e cense: mber ignature o ce um a or as Etter Title ilror »� Master Ucenso Number ' '" City/Town Journeyman W11X7vF f) - C _ , O f - J 2 0 w 7 w U U. LL O a O k D W m w w LL N W S U F - w Y N d Z r r LL N a d O O O h h O w z a Ir O W z O_ h a U J CL CL a J �n O X J