HomeMy WebLinkAboutMiscellaneous - 239 GRANVILLE LANE 4/30/2018N)
Date ..... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..................... U ................... g) ............ K .. .........................
... .. ..... ..
has permission to perform—...-.-,.?
wiring in the building of ..........:'c;:... .. .........................................
at ....... ............................................... ......... ... North Andover, Mass.
U
Fee'�4 .............. Lic. NZ��. ... ............... .... .. ..... . . .. .. . .......
ELECTRICAL INSPE
Check #
90 0
we
Commonwealth of Massachusetts
lug Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. �PU 40
Occupancy and Fee Checked A
[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), 27 CMR 12.00
(PLEASE PRINT IN INK 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) ,� 9 G v't (1
Owner or Tenant Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes [9� No ❑
Purpose of Building(�1�
(Check Appropriate Boz)
Utility Authorization No.
Existing Service Amps / Volts Overhead ❑
New Service Amps / Volts Overhead ❑
Number of Feeders and Ampacity
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
Location and Nature of Proposed Electrical Work: 0
--La auumonat aeiau 1 aestred, or as required by the Inspector of Wires.
Estimated Value of Electric 1 Work: (When required by municipal policy.)
Work to Start G 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 g-SOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: a A,, e i G� i c_ LIC. NO.:
Licensee: Jr K,(\ f -re, Signatur — LIC. NO.:
(If applicable, enter " t " in the license dumber line.) / Bus. Tel. No.: - 17
Address: C exem Alt. Tel. No.: —la SS
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
a-
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11
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ACI SS. � �Hoylndtvidua!); ContraCtors
�' Clan
C1 �Ele tyjstate�zp � please pin L b- rs
Are You o 7 bl
a e pAooyerP check 11
$ p C
enrplo with pArOPriate box: hone #.
$.sole (full and/ 01 _
sh' PrbPrieto�rp�* 4 � a
work and have no rorpartner. have gene! Contractor T -1 %
nVO workers,g for n1e e'rrplo.inyeeS listed erred the srrb,co and I Ype ofpro.
3 D re9viredcomp Insurance
oke SU&COat" wed sheet is 7 (� New o � uire�:
rrr a hOrnepwn S' 13 We �S comp incurs have � Rerrrodelin ction
Yself. er do' are a cO ranee 8, g
r ins f 1 Yo worke � all work Officers rporstion an Q DemOlitio
rrrance j�9uir�d j t Comp, n have exercO d its 9' Buil n
t any appli c ght °f exemption drew IQ drag additio
fio1gep Iot far qt 2, § ! (4) and Per Al ElectriCaJ n
O't�cto who anbth°Xgl m-em1 !
plOYees
we have no Plu repaier;rs oradditions
"�arso comp fNoworkew rrrbingr
rs that this box affidavit indi Sft Out they Iris
2111111, reg
u 12'� Roof epays add
inf °� e °loy� the muatat,�c Lari Ig at? I ey d°►°8 al� sho — their !�d.] /3,� repairs or additions
lnsrrratrC tam �phor�diag wor/� ,mai sheets w d then hoe outside penes. Aoli mer
the
Policy
# e Company Name.
cOmPetts n �r 1 ofrhe sub.�On d the U� i s w afi-
°r Self-ill
elf G'f l. fttkft' °davrtindi
nceformy employ
►nS. LiC. #, o o°cr;P. policy info
°gha8 Suck
Job Site qd , es mto,narior,.
Attach dress: Blow �'rlf�ePolicy airdJnb
a COPY of th site
Failure to s e worms rj(�
fine ecure COv is compen .PiraiiO ate:
Of uP to $150Q erage as safioa P°iic �'�a n D 7
Of up to $2Sp 00 a00 and/or On�qu'red undue S Y deel, Cr "tate O
estrgations
da agai year nnpriso �On 25A of Page (show- )Zip;
of the DIA f°dt Shl
the violator rrrtrI as well A c. !S2 g the Poiic L
!da here rrrsurance Be ad as civil lead to the fi d
Y n� ber an
Si tore c XP and pains tz overage verig . cOpy Ofthisltr in Statethe
ofa sip Of crhnirrapiration da��
o aY be fork. W 0RR OR�enalfies Ofa .
Phone #. _ l , lJ'erjtuY tsar rhe in arded to the OM, Of
a fine
�ci�e on forOnProvrQboye
Crty ort1' Do nor arae m Date. true and correct
ssotng uthI B04 ori �eQ fo6c' S
3_
6 Otherd Y
°f Heai h (2 Buildin Perm • or town olfciQ[
contactg Depar(�pe tt2icen� #
Person; nt 3 Crh�°q,Q C,ier(t 4. Eie
ctr'ica/
Inspector
5 Plnnrbrn
Phone #. g Inspector
- - Ll�'tlOtis loyees.
nstr for their emp
�(�n a ►on contract of hire,
orxia o rovide workers,othPT under anY
loyerso n the $eTvice of
Law 152 req alt en► P� OT any two or more
s chapter e
Otto, an employee is
defined other legal entity, foyer, or the
Ma�chusetts , cor�oT bse tat'�es of a deceased emP the
pmSuant to thislied, OTa.1 °T wTitterL Or► employees' However
�Sflciati
Or imp anneTsh►p, the legal rep employing empe occuP� of the house
exp leggy �ti thereiTi, or, h dwelling „
°`an individual, P and inc}. or, or ohm r v,ork o e an employer
CA is defined enterpnge, association d who resito
s
CA
ed in a )° int
e foTegoing enga an individual, Pa 'aTehthan three VP . t nance, W T ernpto be, del wee or
of the Ot tr►Stce of having notmor, ns to of s e issu
of a dwelling ho"' who emvloys P tershereto shall not because eoc9 Withhoon 'Wealth for any
t� shall
owne'. t ae require
e of arotheC is the cou►m
awe11ingh0'� ds oT building CPP"' '� oi' local liceasibuiidin� coves a„ shall
the groan "every state to construct the insurance cal sub(bv4siot►s ce
OT on 25C(6) BI$O stains hat te a busmess ° of compliance `" nor any of poli", liencewith d`e'ns
152, mitt to °� table evidence' a COMM' idence Of comp
MGL cat
ter 1'►cense or Pe aced accepts s "1yeither tip I �ceptable �'»
rest ut wbo has not p� 157.,' 25w) s o .public work m'� ng author
app►ica MGL chap erformen the co
Additionally' for the P Te$enred t° O►►r situation and, if
enter inta� of thisis chaPt� have been P that a.PPly to y S) of
eckmg the boy-eswits their cen►ficat� s other than the
TeQmn davit Completely, by'beT(s) al°ng with no employ
o hone n s (LLP) LLP does have
APPlicauts , coTnPensation a addresses) and phone
partnershnP if an LLC or of lnd 'al d
the workers s naTne(s), L►ted Liab on insmaT►cc artrne� davit shoal
please fill o ply sub.contractot() Cot sari fitted to the Der 'Che affi aTm1ent of
Companies (LL Womb. ComP� ay be subm date the aff►davi ot.the Dep
neCess cc Lime Liabil � rcQda
uu to car that his a�` sure t° 51$n and is being requested, ° rvi 'to obtain a w°rk�
members or partner, are equlrea Be
advise i co erne.. A`lor the p rnrt OT licensT if y°uare �d panics should enter their
e 4 °yam for colicy i rmatlan of i the aPpliCation pns regard: ding the law Self -insure
pccidersts d to the city. Or tow" ave any q est► the n��T. Gsted below
ould You
at bObom
be ret�n 1 Aca►dents• Sh a-ca11 the DePa' ate Title
tion P° on rovided a Part
the Iicant.
lndustm GcY, Pleas the approp
come sa license number e agent has 4 ou receding the an pplicant
mance D P has to contact beT In addition, an t
self -ins legibly• T" dicating (c
or Town Officials Tete and Pnnred of 1Tivesti tions reference num ne a{{idavit in Or
C►� re
that the af6davrt's e event the Ovr W ich %,ill be us n ed only suW to all locations i°vid ° e
Please be vii for you t0 fill out itllicense numb ons in any ?pv'ZI, Year, applicant Should . Or town may b be filled out each
of the affi fill in the P nse CPP Address ed by the �� davit must venture
please be SUTe to le Perm "tlhee }ob Site or mark A new aff► or �tnrnercial
nust submit rnultipand order dally Stamped
or licenses. d to business dayst
that Must
sir at'0n (if ecess has be
fi for fug e P t relate 'y affi ons
policy » A copy of the valid�dav►t is mining a license or permit
required to o°mPle Ould you have any �u
town) roof tl►atwn leaves etc) said Pere°n for your ration and'
licant as P Owner of citizen is °b cOoPe
CPP where Z. o it to burn
k you 1D advance
(�'a dog license or P ns would like t° than
{flee O{ lnvestt t us a Call. e
.�1e O to number: of Massach,
please d0 not hes►ts telephone and. Convaou��e ��� pGCidents
ent's address,
eparts ent 01 11,
The Dei "' Dvestigstions
mice of 1n
°n Sit
600 Val 02111
gaston�'' 1�p,SSAFE
1_4900 ext 406 oz 1'j
9-71
617 F8, # 61'7-727-7740
ovldaa
www m�•g
Revised s-2�..os
k'
— ) -?
Date ........" ......
,,ORTN
4, TOWN OF NORTH NDOVER
0
PERMIT FOR, NORTH
SSACMUS
This certifies that
has permission to perform,.:. .......
plumbing in the buildings of-7�
.Cr....!
.....................
at
.......... ............ North Andover, Mass.
Fee.- . ...... Lic. . .........:'u ..............
PLUMBING INS'P'ECTOR
Check #
6 2� U
MASSACHUSETTS UNIFORM APPLICATION104,fERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
&4&40'e'/1// 0? Owne
fk`i�"e
Name L •'jcl
Date
Permit # °�
_ Amount I,,
Type of Occupancy
New Renovation Replacement 0 Plans Submitted Yes �. No ❑
0'
1
'
/
i ilk ..�.--..----.-....-...--.
...---....�.�.o5-....�...■
r
MMMMMM
MM
,.r RI' MMMMOMMMMMMOMOMMM
e • MMMOM
■MMMmomM������
MMMMMMMMMWMNMW�
o it
�m����
—
e •
WMNM�e��
i r •
NNN����
(Print or type)
Installing Company Namef yfKrYW 14t60 9, -di'`* / -r
Check one: Certificate
❑ Corp.
MPartner.
�Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy q Other type of indemnity ❑ Bond ❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature IOwner ❑ Agent
I hereby certify that all of the 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. installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By-
SigllaLWe 01 Licenseaum er
Title Type of Plumbing License
iCity/Town icense numoer _ Master® Journeyman ❑
APPROVED (OFFICE USE ONLY
r r
The Commtanwealth of Massachusetts
k1 )i Department of Industrial Accidentt
0 Ice oInvesti ations
•f g
ti. a 600 Nrashington Street
Boston, on
MA 42111
r iw wwhmsgov/dia
ADpLcaFat nformation .
Workers' Compensation 1witrmee Affidayit: Builders/Contractors/Eleetricians/Plumbers
I _
NaMi (BusinesdOrganization/Individual):�
Address:_ 3 ( ��
City/StaWMD:_ tE% zap_
S
Phone
Are you as employer? Check -the appropriate box:
1. F1 1! am a employer
with
4. [] 1 am a general contractor and 1
and
employees (fun and/orpa�etsm .*
2• ❑ I am .a sole proprictors
etor or
have fi red the sub-eontr
listed
ptrfner-
ship and, have no employees
on the attached sheet, i
These subcontractors have
working for me in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. [].We arc. a corporafion and its
required.]officers
3.[] I Idn a homeowner doing all work
have exercised their
right of eaeem. on per MOL
myself [No -workers' comp.
c t52, § i (4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance mired.]
Type of project (required): —
6. ❑ New construction
7. ❑ Remodeling
8• Q Demolition
9. n Building addition
10.[] Electrical repairs or additions
11.�Plumbing repairs
12.[� Roof repairs
I3.n.other
*Any applicant that dieeks W# i mw ziso fill out the section below shovvin ! I
I Nomeownars who submit this affl avit indicarin they atedoing an B their arorkets' oompaisatiori policy mformetion
g e3 B wmlc and then hire outside contnictors must,subm4t a new affidavit ind,caiiq such.
;CoUhuators that check this box Mustataiched an additional shear showirr
g. the name of the sut;•conwketots and their work=�..
ce. ,r, pcFi^.' iriarniadon.
I arc. � errt,{r[oYeT fr_eri L� prcg:W°rkerr' � errsarien
int°rrnafinn. /1 ►nP/ lnsrrranre for ngz eroP[DYe�: Below is the policy acid job site .
Insurance Company Name:_
Policy # or Self -ins. Lic. #:
Expitation Date:
Job Site Address:_
City/StatE/Ztp: �
Attach it copy of the workers' wmpeasation policy deebtri-atSoo page (showing the policy number and expiration date,
Failure to secure coverage as required. under Section 25A of MGLc. 1
fine up to $1,500.00 and/or one-ye52 can lead to the imposition of criminal
ar imprisonment, as well as civil penalties in the form of a STOP WORK ORD
ER and a fin
of up to $250.00 a day against the violator. Be advised that a copy of t}tis statement may be forwarded to the1. e
Investigations of the DIA for insurance coverage verification. Office of
I do hereby certify render the pains and peas/ties oJPerlrcrl' the the nrmation Provided in above is t:ue
J P and coned,
QgJcial ase only. Do not write in this area, to be compAmed bor town off '
Y 1' Jc d
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2-Bnihiiug Department 3. City/Town Clerk 4. Electri
6.Other cal Inspector S. Plumbing Inspector
Contact Person•
Phone #:
Information a ind Instructions
Massachusetts General Laws chapter 152 requires all emp layers 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 afhire,
express or implied, oral or written." 1
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two armore
of the foregoing engaged in a joint enterprise, and includir-tg the legal representatives of a deceased employer, or the
receiver ortr utee-of an individual, partnership, associatioin or other legal entity, employing employees. 'Howeverthe
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 maiimtmMce, construction or repair worst m 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 os local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings is the commonwealth for any
applicant who has not produced acceptable evidence -air compliance with the insurance coverage required"
Additionally, MGL chapter I52, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until-acceptRble evidence of compliance with the insurance
n;quiremertts of this chapter have been presented to the cor tracting authority." .
Applicants
Please fill out the workers' compensation. affidavit oompie--tely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es). mind phone number(s) along with thea certificates) of
insurance. Limited Liability Companies (LLC) or LimitedLiability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' caysnpensation insurance. If -an LLC or LLP dors 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 Iicense is being requested, not"the Department of
Industrial Accidents. Should you have anyquestions regarding the law or if you are required to obtain a workers'
compensation policy, please -call the Department at the nurmber.listed below. Self-insured w rtpaniess should enrP?dmir i
Self -insurance -license number on the approNi ►ate tine.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes provided a space at the bottom
of the dffidavit for you to fill out in the event the Office of Investigations has to contact you regarding the appl'sMnL
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 permit1license applications in any given year, need only submit one affidavit indicatirigcurrent
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 .officiaily stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for futrae permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining s license or permit not related to any business or commercial venture
(i.e. a dog license or permit"tin bran leaves etc.) said pers6r3 is NOT required to complete this affrdaviL
The Office of Investigations would lflm to thank you in advance for your cooperation andshould 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 133dustial Accidents
Office of Investigations
600 Wa&ington Street
Boston, IIIA 42111
TeL # 617-727-4900 ext 406 or 1-9-77-MA.SSAFE
Revised 5-2.6-05 Fax # 617-727-774
www-mass.gov(dia
Location
No. �% Date
_a
TOWN OF NORTH ANDOVER
Certificate of Occupancy S
�'� s'•^° • tt�
Hus Building/Frame Permit Fee $
�c
C Foundation Permit Fee $
Other Permit Fee $
r TOTAL $
Check # ?e,, t_/9
'i
7789 �_���%Idgins:&&
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: /)
_
SIGNATURE:
Building Coinmissioner/In for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
237 roL w v l cP
l
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area (sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Re red Provided
1
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
Public 0 Private 0
SECTION 2 - PROPERTY OWNERSIUP/AUTHORMED AGENT
storkDistrict: Yes ___-_Ne
2.1 Owner of Record
J40/
�s
Im a
Name (Print) Address for Service
7
Signature Telephone
4
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
7-� V''1b v� /�o
060 f r 2
Licensed Construction Supervisor:
License Number
t, 6 h q cu L, Qf�,L (I J'
Addii
����
65
y
Expiration Date
Signature fTelephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
7 kc) W 15 d s 4d
Company Name
Registration Number
�0
( r
() f>
Address
Expiration Date
Signature Telephone
V
a�
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check au applicable)
New Construction 0
Existing Building JV
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. 0
Demolition 0
Other ❑ Specify
Brief Description of Proposed Work:
0- n c6 fed F=
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by pennit applicant
" UI?FICSEONLY
1. Building
(a) Building Permit Fee
Multi lier
2 Electrical
(b) Estimated Total Cost of
Construction
�d d
3 Plumbing
Building Permit fee (a) X (b)
crV
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My be matters rel rve to work authorized by this building permit application.
SiLpiature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
b elo,
Print Name r /
60
Si ature of Owner/Aent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIvMERS 1 2 3
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 FU_LED LAND _
IS BUU-DING CONNECTED TO NATuTIRAL GAS LINE
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WoodPage of
105 Haverhill Street
Methuen, MA 01844
THOMPSON'S
ROOFING
Shingles
- Slate - Rubber Roof
Single
Ply - Copper Work
PROPOSAL SUBMITTED TO
PHONE
DATE
Linda Gagnon
withdrawn by us if not accepted within
STREET
JOB NAME
239 Granville Lane
CITY, STATE AND ZIP CODE
JOB LOCATION
North andover MA 01845
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
Si rip off a.11 roof shinglas on
house front arid, bac;
Install aluminum drip edge around
roof line
Apply ice and water shield 6 ft.
up all along edge
Apply 151b. felt paper on rest
of roof area
Reshingle with a 30 year Anccitect
shingle
Install new fainge around soil
pipe
Cut in a ridge vent
Ramnva al l 1.7nrIr --I n+-o.a 7 Y
we wil pull permits
30 year warranty on material
10 year guarantee on labor
construction lic. #060112
improvement #128612
We Vr0pm hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
Five thousand --------- dollars(,. 5,000 . 00
Payment to be made as follows:
on completion
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner
n
according to standard practices. Any alteration or deviation from above specifications involving
Authori
extra costs will be executed only upon written orders, and will become an extra charge over and
Signature
above the estimate. All agreements contingent upon strikes, accidents or delays beyond our
control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully
Note: This proposal may be
covered by Workmen's Compensation Insurance.
withdrawn by us if not accepted within
Acceptance Of PrOP05ar — The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized to do the
work as specified. Payment will be made as outlined above.
Date of Acceptance:
Signature
Signature 4.i
days.
615i24!2ND4 17:35 6352464
PELHAM INSURANCE INC
PAGE Ll''
OF L I A B f '_ I T Y I N S U R A N C E DATE 05.24.04
i rn ti";:E1. THIS CERTIFICATE IS ISSUED A$ A MATTER OF INFORMATION ONLY AND CONFERS NO Rr3�77
UPON THE CERTIFICA7E HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTKND OR ALTER.
PEUW INSURANCE SVCS INC THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO BOX 960
! 122 BRIDGE STREET INSURERS AFFORD 1 NG COVERAGE
PE -RAH NH 03076- -INSURER A: Nautilus Insurance Co.
!•t.= INSURER B: Associated Industries of Massachusetts Insurance Co.
Thomas Dcyle INSURER C:
rho»Fson's Construction & Roofing
8 hest St
Salem NH 03079
INSURER D.
INSURER E:
THE POL'-'ES OF INSdRANCE L:STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV� FOR THE POLICY PERIOD IND:CAT
.`TaNG1tVG ANY R_:,�UIREMENT, TERM OR. CONDITION OF ANY CCONTRACT OR OTHER DO UMENT WITH RESPECT TO WRICH TH'_
j
F: 51 },y 5E 'ISSUED OR NA'r PERTAIN, THE INSURANCE AFFORbED BY THE POLICIES UESCRI8Ep HEREIN IS SUBJECT TG .A,!_
AND CONDITIONS OF SUCH POLICIES.. AGGREGATE LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PA`.D CLAIMS.
INS
POLICY EFFECT'VE
POLICY EXPIRATION
'?
TYPE OF 1N:,'J;+\iE
POLICY NUMBER
DATE (MM/5D/YY)
DATE (ht4/DD/YYi
LIMIT; I
GEiIERAL _IABriITY
EACH OCCURRENCE
S1,000.OG0
[xl .,,0'EPC1AL GENERAL LIABILITY
FIRE DAMAGE (Any one vire:
1 50,000
A
; f C'_A::MS MADE [x] OCCUR
INC330578
04.15.04
04.15-06
MED EXP (Any one person)
S 1.000
PERSONAL & ADV INJURY
31.000,000!
GENERAL AGGREGATE
12,000,0071
=. jREuaTE IMI. A P! IES PERj
PRODUCTS - COMP;
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111 -
Workers' Compensation Insurance Affidavit
Name Please Print
Location: a..3 (g C1 K,y t ( (? ))
LWa
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Comoanv name: 7VO VIA � I, -,e J-1 C-1
Address 1 6! T f r tA> f n 1 , ( ( S
�N --Q -� t1, L4- -e�
k
Comoanv name:
a we i 0 I Z 2--1 L( U( ZG(d L(
Address
Ck. Phone #
Insurance Co. Policv #
Is
Faiture to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties ot•a fine up to $1,500.00
andlor one years' imprisomient_as .wat .as_chdi.penafttes in the farm d-a..STOP .YORKORDER md..a .fine d.($100M)-a day sgalmt.me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certifya pains and penalties of perjury that the information provided above is true and correct.
under
I(`T_eco
Print
U
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensi
❑ Building Dept
[]Check if immediate response is required
❑ licensing Board
❑ Selectman's Office
Contact person: Phone #. ❑ Health Department
❑ Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
The debris will be disposed of in:
� s u
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
a