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HomeMy WebLinkAboutMiscellaneous - 211 CANDLESTICK ROAD 4/30/2018d This certifies that ate .. ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform . . ........................................................... L .............................................. wiring in the building of ............... � S -i .................................. at ......... ......................... . North Andover, Mass. ..... . .. .. ..... . ...................... ... ...... .. ...... Fee Lic. No . ..... �LECTRICAL INSPECTOR Check # 7 0 Commonwealth of Massachusetts Official Use Only Department of Fire Services PernutNo.J-9-10 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT IN) K OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ZN k C,qh �i� S�, `r K-1 Owner or Tenant M c,..aSew, G,^ - % Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No R (Check Appropriate Box) Purpose of BuildingUtility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed EIectrical Work: 1;%% 4,,kl ( 2 L, Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators \ KVA 2 Z No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. El o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs - Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 07res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1 - 4�7 - I (e Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) I certify, under the sins and penalties gper�ury, zat the information on this application is true and complete. FIRMNAME:. LIC. NO.: 41S-12- Licensee: 1SS12Licensee: V%c ,,,,,,j Signature LTC. NO.: /9 JSJ 7- (If (If applicable, enter "xempt" in the license number line.) Bus. Tel. No.- i o i • qS'"1- - 4614> Address: 7 rMA-it SL '5', 1a,.. , u 4- Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the Y permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed? . on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPE TION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, NIA........dweinhold@townofinerrimac.com t>� The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 _ Boston, MA 02114-2017 www mass.gov/dia GiM SV�v Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians lumbers. p BE MED WITH THE li,W['TTJNG AUTHORI� Y. TO n, ^n no Priv{ Name (Business/Orgab zation/lndividual): � Address: t+- City/State/Zip:_ Axe you an employer? t{- tz,&o� Phone #: ecic the appropriate box: 441 am a employer with _employees (full and/or part time).* 2.❑ I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all workmysel£ [No workers' comp. insurance required.] t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.� 1 am a general contracto : and I have hired the sub -contractors listed on the attached sheet. These sub -contractors bave employees and have workers' comp. insurance # 6. Q We are a corporatiog and its. officers have exercised their right of exemption per MGL c. 1 4 and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ No 'constn ctlon 8. E] Remodeliing 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repairs or additions 12, ; .plumbing repairs or additions 11E] Roof repairs 14.[] Other *Any applicant that checks box 41 must also sill out the section below showing their workers' compensation policy information. Homeowners who submit -this . ' .his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such i ,. tContractors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not (hose entities have rffl,r. cnh-contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site information. - insurance Company Name: r , Q Expiration Date: 1 Policy # or Self -ins. Lic. #: v G.4� 2. � �� . 7 \ � 4� C;«.±�- City/State/Zip: Job Site Address: \ /' • - - g the policy number and expiration date. Attach a copy of the workers' compensation policy declaration page (showin olation 0.00 Failure to secure coverage as requited under MGL enalties2inthe form of25A is a aSOPal 1WORK ORDER and a fine of up to $2by a fiftb up to 50.00 a and/or one-year imprisonment, as well as iv p day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cel un the pains and penalties of pet jury tliat the information provided above is true and correct. — Phone #: Official use only. Do notwrite in this area, to be completed by city or town official. permit/License # City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Phone Contact Person: 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 0l, 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'dr trustee of an individual, partnership, association or other legal entity, employing employees..Howevgr the owner of a dwelling house having not more than three apartments and who resides therein, or the occupani 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 b6 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 applicantwho has notproduced 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 theperformance 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 numbers) along with their certificates) 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 w6rkers' 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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia DATE: 12 - k1- 19 - LOCATION: 21� C4 At-%4%.c pl- OWNERS NAME: mk-C ^�Q=.n % V GENERATOR kw 22 V., NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: Goa ELECTRICAL �RESHDENTIALJ COMMERCIAL TEMPORARY LOCATION OF GENERATOR:yc5t%,i- *ZONING DISTRICT: *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL IP,: . Date.. I ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . ........ c� has permission for'*gas"i*n*s*t*al'l*ation*'.!��.',,P.2.*e-4-YL— in the buildings of .............. . -j 1( . . ................................................... ............................................................ at .... ;i;�.Il ........ ( ........ A ... r ...... A) ... ..... e..4 .......... . North Andover, Mass. Fee- Lic. NO; .................. .............................................. b ............... Check #1534p/ GASINSPECTOR �v� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY -,MA 34 MA DATE PERMIT # 19 2 4 - JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TEL�J�_ _ ��FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: NOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER _.. - -_-_� - - - _—I I • _ — . CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS( -- MAKEUP AIR UNIT ._.. _ .. _ _. I --.- OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER- UNVENTED ROOM HEATER WATER HEATER OTHER I fL�j L -_tel J --=1F INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW, i LIABILITY INSURANCE POLICY -- OTHER TYPE INDEMNITY E] 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 [j AGENT Eil SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the GeneralL ws. O V PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP 0 MGF 0 JP [] JGF UKPGI © CORPORATION ©# PARTNERSHIP ©# 111 LLC D# COMPANY NAME: ADDRESS CITY tfi STATE ZIP TEL FAX �� CE EMAIL Vl � �,,� r .C�Z �v� �rJ o❑ Z fp ❑ U w �* `a w Q U) a LU O � LU W N o a a J E., a a x w ail H LL The Commonwealth of Massachusetts S Department of Industrial Accidents �� r I Congress Street, Suite 100 1'142017 Boston, MA 02 �c www massgov/dia Workers, Compensation insurance Affxdayit:Builders/Contractors/�lectricians/Plnxnbers. AUTHORITY. TO BE PILED WITH THE PEgM[TT'NG Nance (Business/Orgariization/tndividu L, i yr lv Address: City/State/Zip:drip t/ Phone #: Are you an employer? Check the appropria a box: 1.[ Vm a employer with _.employees (fiill and/or part-time). /2.F1 I am a sole proprietor or partnership and have no employees Working for mein an capacity. [No workers' comp. insurance required.] Y 3.❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.F] I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. QWe are a corporation and its, officers have exercised their right of exemption per MGL c. 152 1(4) and we have no employees: [No workers' comp. insurance required.] -silo-- q 74 Type of project (required): 7. [] Nd--Wdonstriici[on 8. [] Remodeling 9. ❑ Demolition 10 0 Building addition I L ] Electrical repairs or additions 12.0 plumbing repairs or additions 11E] Ro6f repairs 14.[] Other applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information *Any i Homeowners who submit•tlus affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating sue $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have rf+HP c„h-contractors have employees, they must provide their workers' comp. policy number. am an employer that is providingworkers' information. Insurance Company N compensation insurance for my employees. Below is the policy and job site Expiration Date:. Policy # or Self -ins. Lic. #: C. ity/State/Zip: Job Site Address: �I Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). e by a ffib up to 0-00 Failure to secure coverage as required underzM enalties inthe form of a25A is a aSSTOP WORK ORDER al violation Iand tine of up to $250.00 a and/or one-year imprisonment, as well as p day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ercation. coverage vifi coverage hereby certify under t7iepains andpenaltie� ofperjury t1iat t7ie information provided above is true and correct. Phone #: 40 61"L 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 Phone #• Contact Person: 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 receivetbr trusted 6f 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 b6 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 applicaritwho has notproduced-acceptable evidence of compliance with the insurance coverage re4idred " 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 Pleasb 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 Offrcials 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 4118 ,e� Date ..... ....... 4� ... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING . ................................... This certifies that ......... T4..� . ........ ( .... ( .... has permission to perform ......... ....... 7-61A, ........................................ ... .. ... ... wiring in the building of ...... ...... 1.0.0n�.4 -1 ... IV, .............................. N h 'kndover, Mags. Fi ee ... '/- ... Lic. NoJ� .................. Check # 5*UcrRIC�AL INspEcrOR ThECOMMONWFq LTH OFM4,Q'�CIJUSMS DEPA WUNXSVEIY Office se only / BOARDOFFIREPREtN17pNHONS527CMt12.� Permit No. Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORMEZ,EMUCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location (Street & Number) _ I) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes PIC 1:3 No (Check Appropriate Box) Purpose of Building ytC 1 e Utility Authorization No. Existing Service Ams / Volts Overhead -- '�� Amps Underground � No. of Meters New Service AmpsVolts Overhead Underground CM No. of Meters Number of Feeders and Ampacity _- Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Lighting Fixtures No. of 5f ecepta :le Outlets 1 No. of Switch Outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of water heaters KW Tubs No. of Hot Tubs No. of Transformers Total Swimming Pool Above round No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons No. of Heat Total Pum s Tons Space Area Heating Heating Devices No. of No. of No. of Motors Total HP Below Generators No. of Emergency Lighting Battery Units FIRE ALARMS Total No. of Detection and KW Initiating Devices KwNo. of Sounding Devices No. of Self Contained Detection/Sounding Devices KWA Local Municipal Connections rut�lJilntlUl[ELIeI�L[eI]pjj�pry� IaWS haw wwbrr iwd ablldyhmuanoePo]icy g ComageoritssubstaletNival�t ha�subrrrrt�dvalid 6s Wtothe0ffv-- YES j'-j�7j� >f x E VSURANCE M BOND MIER M (PJsespec Y)� ✓orktoStart ignedu JJer, eRWkiesofpetjMy: 1 - h RMNAW QAA SrJo,L,,fA lu,durrryNgmmcnttnspe=aM fionwalms ihisrequhmimt lease check one) Owner Agent Signature or Uwner or Agent wo Etntkd VahteofEbgncai We k $ Rough Final KVA No. of Zones a Other Ll —0 LkmseNo BtTel.No. .� Alt Tel. No. byMa%achusetts General Laws Telephone No. PERMIT FEE Date..Y- 26-o Z— .................. ' 6 0 TOWN OF NORTH ANDOVER Vwo PERMIT FOR GAS INSTALLATION T ois certifies that ............ has permission for gas installation : ........... in the buildings of.—, .......................... at North Andover, Mass. -;7 A-, Fee7� .... Lic. No. GAS INSPECTOR,," Check# 5 119 MASSACHUSETTS UNHUORMAPPUCATONFORPERMIT TO DO GASFITI'ING (Type or pmt) NORTH ANDOVER, MASSACHUSETTS Date r13 c) Building Locations �-/ ( °i �cr ` P S1<< cc J�— Pernrit # Amount $ Owner's Name �-� � � � New 1_.1 Renovation Replacement Plans Submitted (Print or type)( /����� �� �� one Certificate installing �panY Name �il Corp. Address 5�� r% x �U 7 Partner. Business Telephone 767-t7- !> Z ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter IJ 0 L INSURANCE COVERAGE Check one: , I have a current liability Insurance policy crr it's substantial equivalent. Yes es Woo If you have checked mss, please.indicate the type coverage by checking the appropriate bmL Liabilibl insurance policy other type of indemnity ❑ gond Owner's, Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. Geral Laws, and -that my signature on this permit application waives this zequkement. Check one: Signature of owner or owner's Agent owner ❑ Agent I hereby certify that all ofthe details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and inalla;iphhs � r Permit red for this application will be in compliance with all pertinent provisions ofthe Massach State C d Chapter 42 ofthe Generals_ (OFFICE USE ONLY) Signature of] QPlumber ❑ Gas Fitter [�aster ❑ Journeyman ;ed Plumber Or Gas Fitter /TO3 License Num57r P4 1,ocation— No. —,/ -;70 Date ev .4 TOWN OF NORTH ANDOVER 0 + Certificate of Occupancy $ Building/Frame Permit Fee $ Check # A -0,;-- I 173 7 0" 7 Foundation Permit Fee $ Other Permit Fee TOTAL s Jo $ -2,') �t —ilding Inspe< �or '" TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: +>� O DATE ISSUED: w SIGNATURE:q —A6w Building Commissioner/I t r olBuildiligs Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use I Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ke4qWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record /2,S6/,3 411 CA0QLC-s71 C/ < "q Name (Print) Address for Service Signature Telephone 12.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ J d�y"' Licensed Construction Supervisor: /23 �g License Number p �y ^ �1 � � ��{J j� -e- v / `/ `J \/-/LG i/JQtf��j Address 3 a oas Expiration Date Signa U Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ ALL lI J O&—k 04JY 96z l= l Company Name c /v l.� �,r�G�J � � \ S� Registration tmber O 3,?—� � O Address � Q PA Expiration Date Si ture Telephone a T M Z O L� Mn ic r M _r ^z Q C ..CTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Q Addition ❑ Accessory Bldg. ❑ DetyC hilon ' ❑ Other ❑ Specify ' Brief Description of Proposed Work.- ork:SECTION SECTION6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit ap plicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total1+2+3+4+5 Uy H Check Number SECTION 7a OWNER AUTHORI TION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/Authorized Agent of subject property Hereby authorize /gut-- ss.±D LA np� —to act on My be lf, 'n al iatter relative to work authorized by this building permit application. siliiag of caner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ,'A as Owner/Authorized Agent of subject propert Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name i at of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS 1ST 2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 lopF! J QCL !s �l R co PA 1� A O ��fl�. 1 #•. O • j n ... 1. v.,r . Mw� J s GO 1 X31 s'1 �. y0� O G m • Iv� v x � �'� •� � e� W s f • t�, It'� c yij�yp 0 t wary er�.� •r low~ "0 ounce e�.ra �ws tare low AA0000rn New I I AW m to i I meram , 0000�iQ and 11aIOW W Ww attd A/ rale AIWO 1. w under OM PAW)Peet to Peen Low, ox ktsuwas A fOW 10 .htlN01e0n It ` *. Wa 4 North MdOrN, INA OiW ` Lre hid MA DIM ; FW b NvrNW: 026US a NCCi Cower Coe• 16 317?1 Risit 10 Me.: -1 743M ower VOWWAaN net NOW 00", Neeree amer z ►dblr I�wloe t e+�vtN! b t 110�Cl00012:01 s� �tsndsrd i+++e at tt►e 0+!>xed a ettuig addraae. 3A. vvwkm Comm"Nal kwjw=. port Ono of Na policy 01,10100 to enol Wa kers CwmpwmW low and sny om*§Mnat db00140 taw of asaN of tM atslae latad hom AA 38. amploy" LI"NNy V+0 WWO: part Two 0f me pocky appW !, Empoy" t6pttty losuro ve br Wa* in esch 200 hard in Ilan 3A. Thy LWft of Udit OW �ouhr ► by soels m $100.000 EadA ErtKi0yee �odlly �'+lu+'1r ey Do"" 3900= polky ; .b it soft Ory by Olsssaa 3100,D00 Eson sodient 3C Dater 84IN Ins *wm part thraa of OW Polley "I" t0 :Ht cups, if ON, tilted here. Ail 0ave oxmpt WV, W 0M, WA. WY, WY area ON" dWAP%MW in OW 3.% c I the 1M rmsr o , pop. 30• Th* nifty i akidee mono en40s01mwft W4 eM MtS&ad setr0ule. o, T ft Or'er I!► �M1t t#!le .._7 wM be dalMrnW4d by OW et +, Rijlao. Cfa j:�l ratbfli, end RW"I Mane. Ai; )niwemebm beim s subleet to verffleati��rt one 4di►wlriwet 01 Prem &W be fro* K. P" enert�a oy+ audte Coram of ooara�lone: � �+.d stt F.Wenoi Con Mont: COWAwmn Low*.rete E:.Vmdite Rnnwr PMMIW' a.ffitc Cee+nter,l0nea 11/7u1pA� ate...... �� �teere C � � a►wt � � 0-14 'sen 0" Nmenr. It any, tsa�,b eo term a OW tnoey{ 09 W" ft 46"PiOYM rte+++ icy, and Dole or loam; a lawt9ft re''m arae, tC zu *4m Cater 4 --Nm! ' -"I knw,'" we 00 00 O1 av oam) rr - t t f~-4W-h&yr 1� U) m Cf) 0 m r C3 y C O � CO) Cl) CD� Z y cDo'v C O CO) n� O cm o p CD Q� cr CD CD O CD co w 9. C CD y o. v y S. 0 cc CD CD � v COD O CD Z O O o CD 0 CD Lel C 0 0 Z O CD O _ co O CCPC a CD tC C O N CL CO) co m C ��O _. N O Q d0 m =' m 0 N A dCD A a O d� 01 -10 N IE O _ ® o f� 0 O N• A . ? N CD ft ft CD O N O m G C',3 N d N _ ad - G m CO) Q C CD .di N = m �n_• A O O CD o CO) CD n CD CD� CDCD: � N o CD CD d--i N = W CD Cl) 3 m H N y CD O � q a m A z O F rn cp PCI z -s ^ 7 O O O O O z a- O O tt O O 2 7 w w y y G c D O �G �C r C x rt O d > d 9 O cn z � z x cn H H ''3 z O F L"'\ � MAQQAW1UJcJ fS UNIFORM APFUCAT]ON FOR PERMIT WUU et-Uf1r1C11V11 Sl..\ (Ptint or Type1 NORTH ANDOVER, , Maas. Date�z /` 19i_ Butfding Permit it Locatlo Owners Name New ❑ RenovationReplacement Pians Submitted: Yes ❑ No ❑ FIXTURE$ - Check one: Certificate Installing Company Name l/ �r (. ❑ Corp. Address ❑ Partnership / m/co. Business Telephone Name of Licensed Plumber INSURANCE COVERAGE: Check one I have a current liability insurance policy or Its substantial equwanL Yes ❑ No ❑ It you have checked yn, please Indic the type coverage by checking the appropriate box A Itabilty Insurance pdicy UOthar type d Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage requlred by Chapter 112 of the Mass. General Laws. and that my signature on thio permit application waives this requirement. Check one: Owner ❑ Agent C]sine o et a Owner s ent I heteby certify that dl of the details and information I have submitted fol enUrdl In above appkAtbn are true and somata to the best of my lnowtedga and that Orf plumbing work and installations performed under the permit Issued for thio appikatlon Mall be In pertinent provisions of the Mauachusetts State Phxnbinq Code and Chapter 112 d is tM at ms. compliance � 'Wo nature Tide t�tylTown /` �/ lkense Number `1 d ,_. APPMVED (OFFICE USE.ONLY) Type of Plumbing Lkansa: Masser M,-- an 0 w w s u tt i < s o w s w A s! w M = o °s a a an ~ ! ! w < < ; H U = Id ! p • 2 ! r!.4 w } < w M ar .. w O e .1 O s � ! O a! O a e. 0 s ut 16 M9 s 3 is rr 1• z»!' s o s u ,°a a ..Id a 4 0 u w o o It w 0 aua—ttsrT. sAeawsHT IST FLOOR 2HO FLOOR SAO FLOOR 4TH FLOOR aTH FLOOR eTH FLOOR. TTHFLOOR 8TH FLOOR - - Check one: Certificate Installing Company Name l/ �r (. ❑ Corp. Address ❑ Partnership / m/co. Business Telephone Name of Licensed Plumber INSURANCE COVERAGE: Check one I have a current liability insurance policy or Its substantial equwanL Yes ❑ No ❑ It you have checked yn, please Indic the type coverage by checking the appropriate box A Itabilty Insurance pdicy UOthar type d Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage requlred by Chapter 112 of the Mass. General Laws. and that my signature on thio permit application waives this requirement. Check one: Owner ❑ Agent C]sine o et a Owner s ent I heteby certify that dl of the details and information I have submitted fol enUrdl In above appkAtbn are true and somata to the best of my lnowtedga and that Orf plumbing work and installations performed under the permit Issued for thio appikatlon Mall be In pertinent provisions of the Mauachusetts State Phxnbinq Code and Chapter 112 d is tM at ms. compliance � 'Wo nature Tide t�tylTown /` �/ lkense Number `1 d ,_. APPMVED (OFFICE USE.ONLY) Type of Plumbing Lkansa: Masser M,-- an 0 T' ' 1.- 1 3307 A :�7 Date. . TOWN OF NORTH ANDOVER -PERMIT FOR PLUMBING N4� This certifies that ...... 01 z. J. has permission to perform . .. ........... ........ A plumbing in the buildings of ... at . .9?. o. . �-Z(('X_. &I'l., North Andover, Mass. F e e 2,1D I-, - . It). .............................. ......... Lic. No PLUMBING INSPECTOR —W 14/97 13:54 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Staple aideis TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Issued: IMPORTANT: Date Received nt must complete all items on this page LOCATION -. I ) C A ND LES,TC it Print - -.PROPERTY OWNER (ZDgCt2-T woA (-I v Pant` 100 Year Old Structure ' yes no RCE ZONING DISTRICT:.. HistorlcQistnct.. ye no MAP NO/i� . _ L Machine. Shop Village _yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 9One family 11 Addition ❑ Two or more family El Industrial ❑ Alteration No. of units: El Commercial 9 Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑S.e`ptic' ❑,Well • ` IFloodplain; 01Netlaiids 'p Watershed District _ . 4 A ❑ Water%Sewer ' - DESCRIPTION UI- VVUKK I U t t: rt:Kr-U 1V1MU: CKiST IVG ASPHALT Sdihz(C) A$J0 WS -11 cc Identification Please Type or Print Clearly) OWNER: Name: ,e096,' % f0-iyniN�� Phone: Address: `2- i-� C4ti'01C5 ICX ,�® A4 4140 vC - - CONTRACTOR Name - Supervisor, s ConstruclonLicense. t Hnrff6'1I 6hrnVAmenfticense:. l6 £3 6, 2 Exp Date:.3- 2,Y -� 3 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT.'$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASE ON $125.00 PER S.F. Total Project Cost: $ 12-000 00 FEE: $ Check No.: d d qz Receipt No.:��' NOTE: Persons c ratting with unregistered contractors do not have access to t guaran unci Signature f`.Agent/Owner Signature of contr c r . MI_-- c+..1....,..44-1 n Dlnnc \Abn4iorl n (,mrfificrl Pint PIA Ded ns ❑ Location-Dw No. Z Date ' Check 4—&-3 v 25687 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL $ Building Inspector Plans Submitted ❑ Plans Waived ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ well ❑ Private (septic tank, etc. ❑ Certified Plot Plan ❑ Stamped Plans ❑ Tanning/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dumpster on Site ❑ Swimming Pools ❑ Food Packaging/Sales ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted- yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Coll nectiWSW nature & Date Driveway Permit DPS' Town ]Engineer: Signature: FIRE DEPARTMENT Temp Dumpster on site yeS Located 384 Osgood street Located at 124Na'in`Street - no Fire Department signature/date COMMENTS v 10 C � CO) n 10 p CD m 0 Z N CD CL o C c >c N <v0 CL Cr CD CD O CD CID v CL Cl) 0 cn CO C I � v U) O 0 o 0 70 CD a CID 140 c� A z cn m n ej n► O D z -h CD N c� O S.W to CD co c 0 0 CL cn m 0 = 'a $ _ ID to rt CD Qm C7 r • m O -, CL 0 o El ,= m _ N N ON C. 0 ill N W N p CD m 2 N m O > 7 O o n CL .r N. GANA CD CD W O O < O O N -h O v N Z CD 0, Cr aN a QQ N < O N C (D ��(D T j ;o O S H �^ O oCL Ln fD CD U) rN -a m m F r (A�^ m A 0 Di O S CD j U) O ' 0 5 a. 5. W C p z Gl M -A•I 0 N m n N m T O �' WO v Om m -r-I 2 CD '� CD m _�. N D N D CD CD 10 as � 0 O O O O CL Ln ( O ID LW .-' oID z C (D T m D m T j ;o O S H �^ O T 3 Ln fD :10 O S m m F r (A�^ m A 0 O S M C W A j _S 7 .Z7 O S T O o W C p z Gl M -A•I 0 N m n N m T O �' WO v Om m -r-I 2 OVAa En D m him m X m m N ui cod CERTIFICATE OF LIABILITY INSURANCE_41 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFMMAINELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), At1THORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate hdder is an ADDITIONAL INSURED, the policy(!es) must be endorsed. if SUBROGATION IS WAIVED. subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on the certificate does not confer rights to the eurfifirato holder in lieu of such mdorseme iODUCER :Occa Insurance Associates Inc lba Water Street Insurance Age V Water street ifakefield, MA 01880 sum Bda Construction Inc 27 Water St Ste 116 Wakefield, MA 01880-3032 (781) 246-3926 DVERAGES CERTIFICATE NUMBER: "-"""-- THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE NNSURED NAM® ABOVE FOR THE POLICY PERIOD INDICATED. E TIFY THAT ANY RE(lU1REWff, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCULIEN T WITH RESPECT TO WHICH THIS INDICTED.MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFOFOED BY THE POLICIES DESMBED HEREIN IS SUBJECT' TO ALL THE TERMS- CERTIFICATEEXCLUS10N8 AND CONDITIONS OF SUCFI POUCIES. I.NTIB SHDAIN MAY HAVE BEEN REDUCED 13Y PAD CLAIMS. UNM GENERAL LIABILITY ][ I COMMERCIALGENEPALLMILITY 8 _ CLAW MADE ® OOCUR R LIMIT APPLIES PER AUTOMOBILE UAMUTY ANY AUTO A ALLOW EOALITOS X X SCHEDULED AUTOS X HIREDAUTOS $ NON-0WPED AUTOS UVBRELLALLAB OCCUR EXCESSUAB CLAIMS DEDUCTIBLE WDRKERS COIpPENSATION AND E6APLOYERS' LIABILITY Y f N C yPRDPIET A'FffWS(IF� N! 3DF3493 4/7/12 4/7 4/6/12 4/ s MDAWGE$ NGLELMIT s 300,000 RY (Pet oft—) S RY (Pet amt) S DAMAGE $ ) S s 11 1 4/6/121 4/6/13 DESCRIPTION OF OPERATIONS I LOGLTtONs /VE]iCLiS(A8.ehA�701,A�BooalRt�rksSd�edWe.Hnwm sP"Cei'l SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THETE THEREOF, NOTICE DA ACCORDANCE OYMITFI THE POLICY PROVISION WILI. BE DELIVERED W AUniORIZEA REPRESEITATNE Caen COCc3 ® 19883008 AC RD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD ACORD 25 (2008109) I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): rQAvC710 ti Address: 2 3X kV J 7,e5l? S-1-/1 City/State/Zip:�W i f 't G O M 000 Phone #: Q;7 IGY /GV G Are you an employer? Check the appropriate box: 1. �4 I am a employer with Ll 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 working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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: >E/?TY M!/7 Policy # or Self -ins. Lic. #: WC /V S e, y 7 00 / J Expiration lob SiteAddress:_2/i C"ID744 oeO City/State/Zip:&. AA�WJIgR IVl09 Attach a copy of the workerscompensation 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 "tne 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 t1senalties of perjury that the information provided above is true and correct. '6� 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 Fax # 617-727-7749 revised 5-26-05 www,mass.gov/dia �iie �panvnweuoea.�� o��iiaaaae�r�selr3 fice of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR egistration:- 168672 Type Expirations_ 3724/2013 Supplement EDA CONSTRUCTION lNC. EVANGELOS LIAPIS 27 WATER ST SUITE 116 WAKEFIELD, MA 01880 Undersecretary ''`'` Nlassachusett� - De1wrtment (if Public Safety Board (if Buifdim, Re,-ulatirms ;tnd Standards Construction Supervisor License License: CS 84795 EVANGELOS LIAPIS 12 STONE STREET DANVERS, MA 01923 �muni�eiunrr Expiration: 5/13/2013 Tr#: 15961 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Dieter 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.$10041000 fine NOTES and DATA — (For department use El Notified for pickup - Date Doc.Building Permit Revised 2010 1 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.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) o 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 ❑ 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 appeal 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 Permit Revised 2012 . CONTRACT # Q O O 1 �3 MASSACHUSETTS EXTERIOR SOLUTIONS INSTALLED SALES ROOFING/SIDING CONTRACT INSTALLED ALSPECIALIST �NUMBER -7 `STOMER " ' ' i0 -p+i 1 STORE NO. STREET ADDR,9SSJ STREET/A{DD/RESS 1—) f. C ')CJ i�-et— -. � ( v r7 ;1 r w CITY STATE ZIP CITY STATE ZIP TELEPHONE TELEPHONE DATELOWE'S HOME CENTERS, INC: S MA HIC NO.: 148688 CASH CB-KARD LGG �' `, F REG -7 FEIN:56-0748358 l[ 4 `CHARGE j P.l IZ This is only a quote for the merchandise and services printed below. This becomes an agreement upon payment. Upon payment, the entire agreement, including the specifically completed pages of this document, the Terms and Conditions included with this document and any other addenda and attachments hereto, shall be referred to herein as this "Contract." PLEASE READ ALLTERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORE SIGNING. INSTALLATION STREET ADDRESS CITY STATE ZIP { YC 1 Color: tyle: rt r r `f .hn 1 r � ccessories: AL., Y-4 * Show drawing where shingles or siding =-_. - - 41,\o -P r - will be installed. Contract Total Are permits required for this installation?: [rJ Yes [ ] No *applicable tax included NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure Trom renovation activity to oe perrormeo in customers aweumg unit. WAIVER OF LIEN and ONE YEAR WARRANTY (TO BE SIGNED BY INSTALLER) I, the undersigned Installer/Independent Contractor, having been employed by the Customer who signed the Certificate of Completion below do hereby certify that the work for this project will be or has been completed in a workmanlike manner and to the Customer's satisfaction. In consideration of the receipt of one dollar and other good and valuable consideration, and to the extent permitted by applicable law, I hereby waive and relinquish all liens and all rights and claims of liens which I, the undersigned, now have or may hereafter have for labor or materials furnished, and further certify that all work performed and materials furnished, if any, by any other party or parties upon the order of the undersigned, have been fully paid for. Further, I the undersigned, agree to cause the prompt release of any mechanic's liens) which may be filed against the Customer's premises by any subcontractor, laborer, mechanic or material supplier claiming the right to file such a lien through work related to the Customer's Contract with Lowe's. In addition to any warranties provided by law or specified elsewhere, including the Customer's Contract with Lowe's, the undersigned, further warrants that all work furnished for this project shall be free from defects either in material or workmanship. If any defects in material or workmanship shall be discovered in the work furnished or material used during the course of the work or within one year from the date of the Certificate of Completion, the undersigned agrees to replace or correct such defective work or material, free from all expense to Lowe's and the Customer in a manner satisfactory to the Customer. I further represent that I have given Customer the option of retaining some or all of the surplus materials or having some or all of such surplus materials removed from the Customer's premises. If applicable to the performance of the work required for this project, I, the undersigned Installer/Independent Contractor, do hereby certify that I have complied with all requirements of the Lead Renovation, Repair, and Painting Program Rule ("LRRPP Rule"), 40 C.F.R. sec. 745.80 et seq., or any applicable state laws or program regulating lead-based paint safe work practices, including compliance with all information distribution, notice requirements and work practice standards in performing the work required for this project. I certify that I have provided the Customer with all documentation required to be supplied under the LRRPP Rule or state program, shall retain all records required by law, and have attached to this document copies of all of the records required to be retained by the LRRPP Rule or applicable state program. Signed and delivered this I Installer (seal) of Print Name CERTIFICATE OF COMPLETION 1. I, the Customer, certify that the Installers/Independent Contractors or their sub -contractors, have furnished all Goods and/or services, that installation, repairs and alterations or improvemnets ("the installation services") have been completed as set forth in my/our contract with Lowe's, and that I have been offered the opportunity to request that Lowe's allow me to retain some or all of any unused, receipted surplus materials rather than have such surplus materials remain the property of Lowe's. 2. Buyer's initials (Buyer INITIAL ONE only) There were no such surplus materials. Date: I accepted all surplus materials I wanted. Owner's Signature I declined to receive any surplus materials. Owner's Printed Name 1;90/ 2-- #90984 (Rev. 12/10) INSTALLER COPY © 2004 by Lowe's.® Lowe's and the gable design are registered trademarks of LF Corporation.