Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 24 ALCOTT WAY 4/30/2018
imd N232Dat"...f.......1--nI ........... r -A ...... ... .. of TN TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ............................ ....... ......... 4 . ........ . ............ has permission to perform .......... wiring in the building of .... .............................. North Andover, Mass. I Lic. NoZ,�!.'I.S . . .................................................... I .......... ELECTRICAL INSPECTOR Check It WHITE: Applicant CANARY: Building Dept. PINK: Treasurer l_ommontvaclUs of //aj7ac{c u:e!t.1 Oriictal Use Only } ear mertf o��ire �ervicz-1 Occupancy and Fee Clieck..d i BOARD OF FIRE PREVENTION REGULATIONS��-- � I (Ica.•e blank) � APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All %vurk to be performed in accordance with the (Massachusetts Electrical Code ( .IEC 527 CMR 13.00 (PLE,ISE PRItVT 1tV 1tVK OR TYPE ALL LVFORLL I710tbj ll itc: `l Ia-1 lot City or "Down of: n , Ao!Y Lbyef� To 11te Insheccor of I'Y7res: ------ By this application the undersigned ,lves notice of llis or her intention to perform the electrical work described below. Location (Street S, "Number) Owner or Tenant �� �r �l.�(� OV TcIepl;one No. W46 Owner's Address Is this permit in coil j�tion with a building permit'. Yes ❑ Purpose or Building IN LAJ (Cllcc!: Appropriate Box) Utiiily Authorizatimi No. Existing Service Amps / Volts Overllc-ld EI `le,v Service � Amps / Volts ON-cr ile nd C Number of Feeders and knipacity Location and Nature of Proposed Electrical Work: Undgrd ❑ Undgrd ❑ ;. of,llcters \o. of :Meters C0711l7iet Poll of "he Ivulq h1b le 171nV hr urirr,t h1' f/11 t., r: V:__ No. or Recessed FixLurcS No. of Cell.-Susp. (P addle) Fans IND. of Total v Trans fonuers KVA No. or Lighting Outlets No. of Hut Tubs Generators K","a No. of Lighting Fixtures AboNe it,, -o. S,}'imming Pool Qrnd. ❑ of ineraency taming J b arms. Batters Units INC. of Receptacle Outlets Yo. of Oil Buruers FIRE ALARl•IS No. o€ Zones No. of Switches No. of Gas Burners No. orDetecuon and ( Initiating Deices 1 No. of Ra totalnges INo. of air Coad. Itio- of Alerting Devices J To :\o. of Waste Disposer, Heat Yunlp `lun;ber ' I ors ! �ti'' _.._.._._ ___......._.._ :` o. of Jeli-Contained 1 Totals: I DetectloiliAlertina Devices of Dish;, asllers SpacelArea Heating KW Local ❑ ttiiunicipai ❑ Other 1 Connection `toof Dr`•ers Heating Appliances IJec_r:ty Systems: . �` Water vV !11o. of No. of - Heaters Si_ns Ballastsoa f De�::.c^� or qui':meat 1' :ecor;munications Wirinc• No. H�dr .:.;ssage Bathtubs `u. o; ,,iotors Tutsi IPF I OTHER: :I!t, cil �GCi.'io+r c.. .>sireC. a :,S r,? INS up_- ,CE CO`' C IZ-* AGE: Un:csS '•cal' by life G'. ,. , no : -.: L: lance :cat '.vor.. the ticensec crovid',s proo`or!icbi, ;nsurancc inc!udir, cor.:p'....ed _.:el. co'It'au-_ or ;Is su, T:: undersigned certii es that such coverage is i'n Force, ane has exhibited prooro sa :e to tt:e _ermit issui::; oC_`ey CHECK ONE. I�SLiL\`:CE� ?0`:DI ! 0-'iiER ❑ (Sne..if•;:) Estlinzt.'d Vattle cF EICCtr;cal \Vor<: (When required o;' aualciDat poilcy.) xU1:< to JtarC Insoccholls to be R:IaestcC; In accordanc- MEC !Z:le 10, ai ,'1L'Cn ecraf}', altd 1. the pants (71t4 prttrtlries of petjuq, theft the information alt :itis rr/ln(icntiult is !rttz 91.'d corrprerc. IrIILI(:ti.a�(E: 13r'nit t, r t -r LlC.N0.:`-- Licensee: C.`fin rt +ti1�-�I Sigaatur LIC. NO.: OGI l t ii1 df%C;li:.;„Id, 2.'!(�• .._airnf;( rl1 il!C itc:ill. 'rttun Gtr ifuC:J l1 el. No:1'-I (� -u+S7-V,4 �`7 + n 11x1 1i1�� / Bas. , , :�ddress: l55 W,"St S� S1t !1 alt. Tel. .No.: t I?- `a�`-y MN N'ER'S INSURANCE V,`AlVER: f am aware that the Lice;see doe: act :Pate the iiability insurance nor^.ail", couircu ov taw. D ..n'. sl,naturc below [ ilercb}",,ai, this cui,cmc:u. ...,..:'le (chcc`k arc) �! ow o u. ger _I tt ;:c s a., Ott Signature Teleptlorc\o._ PcR1111 FL : S3 < 00'0 0 _ w="•< a cn � Q -o c� Cl) 0 Q. 0 3 m N z c ? �� N O N °r (D T rt Q. O ' MR C o` G/ y CD W v► O -� CD CD 2D 0 am y CL 0 t/1 0 ca cCA m 0 Q 0 CD W CD ' D O� �� 0 (a m CL_ = Z o �. N n � 0 Cr nco O m o �� z� N �o�� co < 0 Q. = y �� Q CDN cfl� O 70m �3� Z %< =r O d0 0 0 y n D N N 91) -0 O at O O 3 CL K W c CD =3 z O /v c I=", ID 0 0 c 10 �J f S 'a O O � CU N H > W �o -n c L O N O 'a O O � CU N �o -n c L O c 'a O aro ' T a n' CU N c 0 z c� z H m O W D v O T x m D r4 x O y 0 a GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/cover and outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace comers and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode SIR wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36 " high, Baluster max space 4" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). ificate of occupancy required prior to occupyinq structure Iq I, D O Z 0 m N 2 7 to O C Q. CD U2 co 0 N O O A -O 0�Q-� o 3� O y FD - 0 0'3o�i CD rL 0 N O O to o- r CD N O O n�. C <D CD -a : cO O G C O 0 N h O 0 DcD =: CL 0 0 CL CL � H ra cn .�-► O O co. O o r�► rt 3 (D O Cn CD a Cy o �. D CD CD -D'a A) o CL C. CL co Ln 0 W v 1 (0 N \m O O c c N M a C � S m i "r S VQT T cu O h CD O .0 h (D m� ti CL O 7 00 n F; 3 Co _• O m cI't >to 10 O M <vC CD M O Z. r -L m tiC E O CD h CD OCD N ( O Z Z CD n O y U2 CD ;z O v O �• CA CD o O O O p Iq I, D O Z 0 m N 2 7 to O C Q. CD U2 co 0 N O O A -O 0�Q-� o 3� O y FD - 0 0'3o�i CD rL 0 N O O to o- r CD N O O n�. C <D CD -a : cO O G C O 0 N h O 0 DcD =: CL 0 0 CL CL � H ra cn .�-► O O co. O o r�► rt 3 (D O Cn CD a Cy o �. D CD CD -D'a A) o CL C. CL co Ln 0 W l O 1 (0 \m O O c c N M a O o Om 7r M ru r(o S m i "r S VQT T cu m� v _ O 7 00 (n * 3 F; 3 Co m n \ c c M Z CT D tiC GI O 7D0m N ( Z Z Z n p O GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/cover and outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations '/s " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. % of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8' solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36 " high, Baluster Max space 4" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). :ertificate of occupancy required prior to occupying structure. 49973 Date 6� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �j�ii�....................... This certifies that., .vk."�.. . t has permission to perform .. !!�!7 (1h Pr ) p, 1 . • .. . plumbing in the buildings of � ............... at .. a 4 ..4.fi` .,, * — W,!+.� _ • .. • . • .. • . , North Andover, Mass. Fee . 10 .. Lic. No. ►2.�i�... . A ................... Check # b�-o 1-77 � PLUMBING INSPECTOR 5�3�I�3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY ,09.1!._f �€J MA DATE _.� / I PERMIT# I� JOBSITE ADDRESS _M OWNER'S NAME F4 POWNER ADDRESS "'�� ' __.-- - i TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q RESIDENTIAID�,]I PRINT CLEARLY NEW: F RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ! _ ._I J _ [ I I I i J �.._( ` CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! (, . _ I ____I DEDICATED GREASE SYSTEM �J .. I ( ._.....__.J .--...._-{ _-._......._.! J _.._._..-_J ...___._J .___..J _.._..___! J ...._._.__I _ ! _ __J DEDICATED GRAY WATER SYSTEM I --.._ ! f ___.-... _._..J .. _..._I _ -_ (_ J .___..J ._.._.J _ _-_J I f DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN I FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) _ I ._.__._i .____-_-( __..___..i ...._.__I ! ..._.___.I ------- ._-____J _.____J KITCHEN SINK LAVATORY _ .._IJ ..__..._.._J ) J ....-.__.._1 J I I .__._.J ...-__.__J ._._-_._. ._�J f _...-..__I ROOF DRAIN SHOWER STALL --J ._I SERVICE / MOP SINK TOILET " _._._. 1 _._-. _... I _—..? URINAL 1 _-1 _._( J .__._.J J _- ._J i -__- I WASHING MACHINE CONNECTION I . ! J ._ - ._ -_l f - _ _ J. . ___ ; I _.� - . J . _. .. WATER HEATER ALL TYPES WATER PIPING OTHEP .._. __. ...____i I —_.l I ._..-....-..I ._.......J _i l J ._._.-... I f I .J �i ...�I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESIX NO P IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC0 OTHER TYPE OF 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 0 AGENT �0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will beiD:npll'th all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ Ol°�. _ .__.P_ . �__..`_ _ .. .. -. __. , LICENSE # SIGNATLIE MID JP0 CORPORATION D44 PARTNERSHIP 0#=LLC __i COMPANY NAME , iyor _ .rl`{Tztl.�►y�� f�c'f�t DDRESS V -e' -- - -- ----_ -- --' CITY LC{—STATE t11 ZIP Bl TEL �7�(D ✓ cS_ r 0 OR FAXCE+f?�� 7 ;LL f 6 _*?, _...._-E EMAIL H O z 0 H U W Fa A W o o z z >- o 0 CA w W O W CL Z �ULLI , _ a c d O z a a U J IL IL Q s w W Ey O z z H U W Un a z� a x C7 N O � ,Y r The Commonwealth of Massachusetts Department ofIndustritrl 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): 63n h!�t Address:_Q City/State/Zip: h! G I ®JCC Cc( 0 Phone #: 9 2 Y_ C- C 3 S- � Are ou an employer? Check the appropriate box: Type of project (required): 1I am a_ employer with 4. ❑ I am a general contractor and I 6. E] Now construction employees (full and/or part-time).* have lured the sub -contractors �• E] Remodeling 2. El am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] 3. ❑ I 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.❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp, insurance required.] *Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information. i Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information.I f Insurance Company Name:. V �,jt o C t 4-\neovton-S, 0--� — ! q Policy # or Self -ins. Lic. #: W L C L2 6 O Expiration Date: d ! 1 / Job Site Address: o` ( #I co %t w City/State/Zip: % OYAy 1 P & / 114 - Attach a copy of the workers' compensation policy declaration page (showing the policy nuniber 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby Aerttqunder the pains and penalties of perjury that the information provided above is true and correct. o? 9 ka-(O Date: ©S 0 ` g) �F& k 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 #: Informati®n 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 producedacceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: T`ho Commonwealth of Massachusetts Department of Industrial .A.ccidents Office of Investigations 600 Wasbington Street Boston, MA. 0211.1 Tel, # 617-727--4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-•7749 WW W.MEtsS.gov1cUa 10 . Commonwealth of Massachusetts ` .Department of Public Safety Oil Burner Technician Certificate License: BU -129058 JOHN P ELLIS 9 TANGLEWOOf) Py Billerica MA 01821 r Expi Commissioner nim, Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -079840 : ,%,l` i JOHN P ELLIS 9 TANGLEWOO)i J Billerica MA 01821 r Expiration Commissioner 01/11/2015 Consumer Office of Affairs & B sifi- m CgS!aq HOME IMPROVEMENT QdNfRACTOR ®. Registration: 13781.6 TYP?s'- '� E�cp ration .1f9/�013: Private C~orpor-a_tiof. =RS C0"NTRAGTIN6& SERVICE INC. - t ELLiS GW -0 -AVE g p RICA, MA 01831 a -� YUnderseclretary q 1 -- _, - 61 3?ttiie,� �itsffrs Enuirnnnlrattal �rafecfimr _�ge#rr1 t:liis is to rertif{{ fha# s ru.•.� ca�e,�u„a a semces, iM. 311 the3urishirfinn nf: AlE n�r.:itiv_N5�%K iMeiam i•e�u__ - iW amlr,+6eYi haMY.a�:�w aha M+��Y��N. S��O15qq yti_Mi0 VGny R1q [iM -_ .. '.gym t,� lw;. M°�•.�, +k Minay:{i 9mN --*N O. MC NWEALTM aF tIASS: CHUSE_T9 PLUMBERS^AND GAS -41 T°ERS REGISTERED AS A PLUMBING CO �P 3 ISSUES THE ABOVE LICENSE TO: - 1 � 2 RIVERS CONT &.SERVICE INC r 9 TANGLEWOOD AV,E ,.1 - 4 BILL- to 1MA 01821=2422 25,8905/1/14 , 1643'3 # ",'` bMMONNVEA1.TH OF MA8-SACNUSE77S PLUMBERS AND, GASFITTERS Lll fNSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: ri A -JOHN P ELL(IS i 9 TANGLEWOQD AVs _A { BILLER1CA X1 1,821-2422 12977{05/'U1/1=4 I 16435'4 ; LOMMpNWEALTH ©F MASSACHUSETTS a ..a M_�'.^.. - ��+'f SHEET METALWORKERS AS A,MASTER-UNRESTRICTED ' ISSUES THE ABOVE LICENSE! � 4 .1QHN .P ELLI'SI 13 t 9 9., TANG:LEWOOD IAVEF t B It- LERICA INA D18�21-2422 Location 2 41` t No. — Date Check #_m 26456 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �?O` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 7'1 0. S -h --j B ing Inspector Permit NO: Date Issuec TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 45 Date Received IMPORTANT: �Applicant must complete all items on f e';o . 11 �fOR'ORERPWOWN �V Residential P'HA't tv ZONING)®IST�RIC3T M- 0 Industrial D Addition AJ;W o or more family 0 Commercial A -Alteration _61 es. TYPE OF IMPROVEMENT— PROPOSED USE Non- Residential Residential 11 New Building [I One family 0 Industrial D Addition AJ;W o or more family 0 Commercial A -Alteration No. of units: 0 Others: -Repair, replacement [I Assessory Bldg emolition eptic' .-.-iEl Well , 0Other D E.166diq[ Ppd' 'Watershed � District , .0, L nC_1A1r'1PL< Tn RF PERFORMED: 0- C, )qo i - k Lc' W n ca //0 �e SC -C- - 94���� Identifigation ease T r Pripf C)early) 6F 7 C'hp I& /- Z ct - 2 OWNER: Name: 17 � L TX '4qq 1,6L Phone:9-2 _W Address. G3COAh) OAr _� N TO -7 CTWN -i 17 lEk ,,Date: Supervisor's Construcfi) kense 'J 0.1i H ryi e 'I Wbv qrnen Eicen ARCH ITECUENG I NEE Phone: Address: Reg. No. FEE SCHEDULE BULDING PERMIT: $12.00 PER $1000,00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $E Jo �bo-o����FE : $_ /R® — 49 Receipt No.: Check No.: �u ar a n fy �fu fund NOTE: Persons contracting jN'th unregist contractors do not have access to the g "Sig.nature of A 0obwne'jr Ll tamped Plans D 4DXAf Certified lot Plan Plans Submitted Ll Plans Waived D C' LIVD J Building Department The following is a list of the requited forms to be filled out for the appropriate. permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Bdilding Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses u Copy of Contract o Floor Plan Or Proposed Interior Work o - Engineering Affidavits for Engineered products COTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application u Certified Surveyed Plot Plan o Workers Comp. Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses E3 Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (if Applicable)- u Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products ?OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) u Building Permit Application o Certified Proposed Plot Plan a Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products g0TE: 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 subm;gted with the building application Doc: Doc.Bui?ding Permit Revised 2012 Plans Submitted 11 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OFSEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/BodyArt ❑ .. .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 d U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION COMM HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments L Water & Sewer Connection/Si nature sate Driveway Permit D -PW Towi2 Engineer: Signature: FIRE ®EPARTMi l T -Temp Dumpster on site yeas Located at -124 Main 'Street Fire ®epa�.frner`it si�natiireldate COMMENTS 384 Osgood Street Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions_ Total land area, sq. ft.: ELECTRICAL.: Movement of Meter location, east or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine )oc.Building Permit Revised 2010 Location No. K22-13 Date ) TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee �.p. 0, TOTAL C G" $ Check # 1� ��`� 3 G ' Building Inspector 273€ 5 y � z CD O Cr � s Q �. V� � O CD C 5 cr s -'1 cD O W W CD �O c F CD �. O LwJ N O 0 CD s CD CD v O 0 CD0 \Y CD N 0 CD 0 2. co rt CD o=� � _ 0 N CD Cl) <D CCD o � C7 0 C) a m o =r.0 N.. � t/1 �' T_ O O rt Q 0 T �� U) o CD CD_ r o T N�O� o d CD =r o g� y rt �= c :don. I s r* �� :� D 0 �- 0 :V �' ;i• Q 0 O CL N �� 0 C CD 0 :NQ 7 r� 0 l�D 0 O 3CD CAs e CD 0- DCO � � r 0 Q1 0C3 N W T Z1 T Ln .Z7 T � r m T Ln T m ;a U p �' �' S p O fD O 0 1 7 0 m C Z rt, �D rt S To N S � on S 7 C cn �• o z Z M ° L N n (D rt m M W - N 3 (D Cl) m C C = G1 Z c� O z o cn 22W a ° X n z T� N z CD N 0 CD 0 2. co rt CD o=� � _ 0 N CD Cl) <D CCD o � C7 0 C) a m o =r.0 N.. � t/1 �' T_ O O rt Q 0 T �� U) o CD CD_ r o T N�O� o d CD =r o g� y rt �= c :don. I s r* �� :� D 0 �- 0 :V �' ;i• Q 0 O CL N �� 0 C CD 0 :NQ 7 r� 0 l�D 0 O 3CD CAs e CD 0- DCO � � r 0 Q1 0C3 O • W N W N W T Z1 T Ln .Z7 T � T (� .Zl T Ln T i ID p �' �' S p O fD O 0 1 7 d C rt, �D rt S N S on S 7 S a o z M ° L N n (D rt m M W - N 3 (D m C C = G1 O o 22W ° X n z z O z cn D r G) O D z 0 m m m y m 0 0 0 x O • W N W W or LwJ y �G O 0' C LU CD CDUCD- iv 0 0 3 C CD 1- C: '0 �� cn 0 m O� z cnI c cn z cn n --I VJ v z z cn a O 0o-0 - =r-1 N = <, 0 N CD M 0CD 0 Q m o s = -0°a N.. -4 v► C -n 00•+C m h::h =r CD N W 0 -4 CD CD_ CL c 0 � O O CD `D • CD -0 CD ;..r _ •� ��� D(D c° n :.Op • CL 0 `� P < C 0 CDZI,C �CD .N r'o 0 0 rt 57 O C rt O �C C CD CD 0 0 D0 rt � O c7 fl1 0 3 � Ln 7 O 'T (D r+ LA -, m OCG rM Z W C 3 m m D m _T O ;u O OQ S D m O T O VI � 7o O S Pm� m 70 f1 >_ Z ►�*+ _T � A O m �" V C 3 W Z m 0 _T � (1 _S (D ;u O UQ T c 7 �+ 0' =SW C 2 ° z H v m 0 fn -a 't C A < h 3 T O Q \ n S fD D W D M o = m D s O w N W O N C M 0 10 CD mo -0 2) �o cam. cin 1 � o � 0 CD 44 o CD CL c =r CD CD o cD 0 CD o cn t• C I � v 0 10 z CD n O o 0 CD C z � � Cl)� nrn o� z -ca v m C Cl) 0— z z ic cnO �Z V/ cn v C) z cl): m: 0 /� b ♦ / o O T CD O. CCD n - Ci °„ m c 3.0 U) N rt (D T OOrtCL m - h ::h a) y W Fi. 10 � N O -� cD _ 5 � o c� CL �. c mc, Err .� 00= �_ �' ., Z ° Q O �Cfl �. CN D A) CD CD U) 0 A\ :k. ID O o� n CQ O' r ID CRD C� CDN D� C� � O O � O. DO 4J v y 0 a r v N M T :° T V1 7,7 T Zo T (� 7J T LA T rO rt O C j °- O opo S O °- N fD O oa S O °- O aca 3 O' °-' _S 3 7 O m S O 0 O-rD O m ° n LA N O a n Z! m V -Z-I G1 � Z LA mCA m m � D f- M m 0 V C W Ln rn a 0O 0 O W C p z V1 m � rD 3 S O m W D O O T m D 2 R� rA rA Is M 41 i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 10,000.00 m $ - $ 120.00 Plumbing Fee $ 15.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 15.00 Total fees collected $ 250.00 24 Alcott Way 822-13 on 5/30/13 Remodel Bathroom CORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDA+YYY► 5/30/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(3), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 this certificate does not confer rights to the Certificate holder In lieu of such endorsemen s). PRODUCER MTtlBxain®rd Inc 1A Andover toad Billerica MA 01921 RAMS; Scott Leavitt, CIC, LTA PHONE (979) 667-9031 wm 667-1010 e' scottl@brainardineure.com INSURE AFFORDINGCOV13RAGE NAIC0 INSURERA!Sentinal Insurance CoMEMX4 LTD 11000 INSURFD 2 RIVERS CONTRA,CTIM & SERVICE, INC. P.O. BOX 1512 ARLINGTON MA 02474 ilisuRcPD.Safatv Insurance CompAjAy 39454 INSURERC.Twin CitX Fire Insurance 29459 INSURER D' INSVRER 9; INSURER F. COVERAGES CERTIFICATE NUMBER•ma®ter 2013 Cart REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WTR SA TYPE OF INSURANCE ADDIL BURR POLICY NUMBER LIC EFF /14/2019 POLICY /14/2014 LIMITS - A GENERAL LIABILITY X COMMERCIAL GENERAL I.IAeILrrY CLAIM"ADE Q OCCUR X Blanket Addtl inured DBSBAFV3267 EACH OCCURRENCE S 1,000,000 DAMAGE tO REP rEff- nwi $ 1,000,00 MED FXPjn one rSon) $ 10,000 PER90NAL&ADVINJURY 6 1,000,000 by _ contxam _ GE=NERAL AGGREGATE $ 2,000,000 GEWL AGGREGATE LIMIT APPLIES PER: X1 POLICY PRO LOC PRODUCTS - COMPIOP AGG R 2,000,000 $ B AUTOMOBILE LIABILITY ANYAuiO ALL AUTOS FO X SCJTEOULED OS HIRED AUTOS X AUTOS 1:0 6206146 /6/2013 /6/2014 C U SINGLE IMI;' ga,e eldanl OODILY INJURY (Pat poMon) $ 100,000 BODILY INJURY (Per eccldera) S 300,000 Rei aw a DAMAGE $ 100 000 ndlool s 5 000 VMDRELIA LIAII MCM UAB H OCCUR CLANS -WOE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS' UABILT;Y ANY PROPRIETOR/PARTNF,RIEXF.CUTIVF, YIN OFFICERA4ENSER EXCLUDED? (Mandatory In NH) If yYoo doseNbo r DES�RIPnQN OFunseOPERATIDNS BPlnw NIA 8va6GL7[6075 /14/2019 /14/2014 X I WC STATU• OTH AEL E.L. EACH ACCIDENT $ 500,000 E.L DISEASE - EA EMPLOYF4 $ 500,000 E.L DISEASE -POLICY LIMIT S 500 ,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VENICLES (ARach ACORD 101, AddManal R makA Schoduln, Nature space Is required) Plumbing and Beating Contraotor (978)688-9542 Town of North Andover Atter: Building Department 1600 Osgood Street North Andover, MA 01845 R -Lim" A, I}6u7 WUD) INS026 (20100501 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Lerlvitt, CTC, LTA/S 1919OU-2010 AGORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD This faire satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language se protest homeowners. Seelt IegaI advice if necessaryAn Massachusetts Consumer Guide to Home Improvement" before agreeingtoo anywperson planning rlcuon your residehome nce. should obtains free a copyho �e Office of Consumer Affairs and Business B egulation's Consumer information Hotline at 617-973-8787 or 1-888-283-3157 or on our website.g ' HOl]leOwilL'r �II�Orn➢.�.�,71®ID. Name 02 �,� n . T ✓� ii'actgx I n,1FQDll'IlDIla'�I.O /^ Company Name street-Addressn is _l l(do not use aPost Office VI /P Box address /r ) Contractor/ Salesperson/ Owner Name �--PCity/Town State Zip Code ��� BusinessAddress(nntstinclude.aslxeetaddress) (O �t Ll C� sip vtir � g� `/P�-c c�j �j, �mz • D'aytimePhone Even 93?hone CityTovm State Zip Code Mailing Address at 9-7 / & (5L Business Phone Federal Employer ID or S.S. Number IiomeAnprovementCtmtmcrorSteg.•Number inw rcgn;res tbnt most Home Sxptratlon dnte improvement cantrnctors 14q , a valid registratloa nnmBcr The Contractor agrees to do the following work for the Homeowner: (Describe in detailthe woricto comps ed, speeif Sthe type brand, and grade of materials to be used, useadditional sheets ifnecessa acJ ►fo' PL-jMV\.a r'ha -Britt( •fZ, r SCI u 4-,,- ( Sha � � 5 1 Fwd 1 br�('�• fv 1� x�sr fn, J<2 d ill b Permits - Tjhby e contractor as gpermits are required Proposed Start and Completion Schedule -The following schedule will and will be secured by the eontracior as•the homeowner's agent; be adhered to unless circumstLhi beyond the contractor's control arise (Owners who secure their own permits wiu be excluded from the Gualranty FIMd provisions of t� MGL Chapter 14ZA.) will begin contracted work. work will be substantially completed. Total Contract Price andPayrrient Schedule The Contractor agrees to perform the woxlc, fmm'shthe material and labor specified above for the total sum ���%' , Oja Payments will be made according to the following schedule; -L upon uponnsiigning contract (not to exceed 1/3 of the total contract price or the cost of special older items, whichever is greater) $--�—�= =— by 0-6 / or upon completion of d / S e cn, i 4 •e C_+� $ o by/ ar upon completion o£ /I� (z2i� �, d� $ upon completion ofthe contract (Law forbids demanding full Payment until contract is completed to bothparty's satisfaction) . The following materiallequipmetttmu;,t be special $ ordered before the contracted -work begins in order to be paid for to meetthe completion scbedule.(-**) $ to be paid for N®TRS; (*) Including all finance charges (I"') Law requires that any deposit or down �w;.nent nequired by tUe contractor before work begins may not exceed the greater• of (a) one third of the total contract price or (b) the actual cost which must be sgeeial ordered in advance to meet the completion schedule. of any special equipment or custom made material Subcontractors - The contractor agrees to be solely responsible -for completion of the work descriUed x Tegaa dless of the actions of any third ontract party/subcontractor utilized by the contractor. he conttracor further agrees to be solely responsible for all payments o all subcontractors for Materials and abol a this aBement Contract Acceptance -Upon signing, this document becomes abindiag contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. ° Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear ° Make re the contractor has a vat' d Home Tm subcontractors to be registered with the Directorovenient Contractor Re 'stration. The law requires most home improvement contractors and r ofHome Improvement Contractor Reg�lstr requires yon may inquire about contractor registration by writing to the Director at 10 ParlcPiaza, Room 5170, Boston, MAy calling ar 888-283-3757. .02116 or b Does the contractox have insurance? Ask the Contractor for his insurance company information so that you can confum coverage, or ask to see a copy of a "proof Of insurance" document. ° 1�now Your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home improvement Contractor Law; 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 ordia third business day following the sl, gr 'mail Pond, by telegram sent m for delivery, not later than midnight ofihe g fining of agreement Seethe attached notice o•P cancellation form, fox an explanation of his right. D® NOTSIGN T -MS CONTRACT IF TBERE Two identical cc ' s ofibe contract must be completed and signed. One copy should go to the IFA_ mcoVRE o6`ep� dSPACEb h contractor. Homeowner's Signature COn Or's Signature Date _ Date Couiraefor Arbitration The Home Improvem eat Contractor Law provides homeowners with the right to initiate an arbitration action, (as an 'alternative to cotut action) if they have a dispute with a contractor. The same right is not automatically affordedto a contractor, however. The contractor would have to resolve any dispute he/she has with a homeowner -in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby n: utually agree in advance that in the event the contractor has a dispute concerning this contract; the cont, actor may submit the dispute to a private arbitration frm which has been approved by the Secretary of the Execlttive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submi%t to such arbitration as provided In Massachusetts General Laws, c apt 142A.. (12 Homeowner's SignatLtre ntracEor'signattitxe o2� NOTICE: The signatures of the parties above apply only -to the agree ent ofthe parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alterative dispute resolution even where this section is not separately signed by the -parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law (MGL chapter 14.2A) and other consumer Protection laws (i.e. MGL chapter 93A) may not be waived in any way, even by agreement. However, homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded'from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work. as described, in: a timely and worlonanlii.e manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties Provided by the contractor, all goods sold•in Massachusetts cavy an implied Ikarrauiy of merchantability and:Etness for a particular purpose. An enumeration of other matters on which ffe homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If yo have questions about your consumer/homeowner rights, contact the Consumer Information Hotline (listed below). (Execution of Contract The contract must be executed in duIicate and should not be signed until a copy of all ex1ibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marled as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the, original contract must be in writing and agreed to by both parties. Contracted work may not begin until both pat Cies have received a fully executed copy of the contract, and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the.payment schedule in cases where the homeowner deems him/herself to be financially insecure. However, in instances where a contractor deems him/herself to be financially insecure, the contractor may require thatthe balance of funds not yet due be placed in, a joint escrow account as a prerequisite to continuing the contracted work.. Withdrawal of:tmds :from said -account would require the signatures ofboth parties. :additional Wormation .If you have general questions or need additional information about the Home Improvement Contractor Law or other constumr rights, or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation. 10 Part. Plaza, Room 5170, Boston, MA 02116 617-973-8787,'888-283-3757 or`visitthe OCABRwebsiteatm://ww�v.mass gov/ocabr/ If you want to verify the registration of a contractor or if you have questions or deed additional information specifically about the contractor registration component of the Home Improvement Contractor Law, contact. Director of Home Improvement Contractor Registration Office of Consumer Affairs and -Business Regulation 16 Parl.Plaza, Room 5170, Boston, MA 02116 617-973-8787, 888-283-3757 or visit the HiC website at littp://wvnv.tnass gov/ocabr/ Go online to view the status of a home Improvement Contractor's Registration: hit13://db.stafe.ma.Ila /hotneim »rovement/]icenseelist asp For assistance with informal mediation, of disputes or to register formal. complaints against a business, call: Consumer Complaint Section Office of the Attorney General. 617-727-8400 AND/OR Better Business Bureau 508-652-4.800, 508,755-2548 or 413-734-3114 Version 2.1-11/2212010 The Commonwealth of Massachusetts Department ofIndustrial Accidents 07 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): L4 Address:_' 1 i`T rl 142 W City/State/Zip: Ai /I art C,( o Phone #: Are ou an employer? Check the appropriate box: Type of project (required): ,Weam a_ employer with 4. ❑ I am a general contractor and I 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. # El Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] 3. ❑equired.] 1 am a homeowner doing all work o 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.] i q � employees. [No workers' 13. ❑Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that cheek 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. r,4 'C,( Pk�j 1-fWOlu-' `7S Insurance Company N V Policy # or Self -ins. Lic. #: 62 1.,T (07 Expiration Date: D/ f l 7 Job Site Address: C2 f //1 60 kt , City/State/Zip4 Al Attach a copy of the workers' compensation policy declaration page (showing the policy nurhber and expiration date). Failure to -secure coverage as requiredunder Section 25A of MGL o. 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. Ido Hereby Aert�,under the pains and penalties of perjury IIIat the information provided above is true and correct. Date: ©S 1;(D `_ I-) ala 0 Offccial use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfUcense 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 #: I Office of Consumer Affairs & Busibess Regulation OME IMPROVEMENT CONTRACTOR egistration: (74974 Type: xpiration:,:;,4/5/20-- Corporation' 2 RIVERS CONSTRUCTION `& SERVICE INC. JOHN ELLIS 9 TANGLEWOOD BILLERICA, MA 01821 `� ` a Undersecretary t_ J i I i. Commonwealth of Massachusetts Department of Public Safety Oil Burner Technician Certificate License: BU -129058_ JOHN P ELIJS 9 TANGLEWOOID Billerica MA 01$21 r Expiration: Commissioner 0111112015 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Superr•isor License: CS -079840, kAJOHN P ELLIS } 9 TAN43LEWOO)if Billerica MA 01821 r t IN Expiration Commissioner 01/11/2015 ✓�lc/� Qffce of Consumer Affairs &B _sWess Regulation HOME IMPROVEMENT CONTRACTQ Registration 137816 TY0* s Expiration: 1/9/2013. Private Corporation MS C.ONTRAOTING& SERVICE.INC. 1 aLEWOOD AVE RICA, MA01k1l i Undersegretary z 1111iteb Otates EnuirojunrIT1,11 prutertiull AgrurB' ++chis is it, rertifil that Y7,—c f� 8 P.ro"s, Inc. r a� I b IiNW Yv ��=�tl6n+w lbswnn RA'AlSnas Vr, b.m:..i m.sxba MnW. ry All 0eJurisbirti6lt ,1 FnA�e.ny iN 5 :q TMv�. anE Tam 'i M.mMwMOM AnbW -. w.e.T:y �.H I.': - MQv .i�� laal.lynY !haw N�V•'�9nnm i.,+ .. COMMONWEALTH OF MASSACHUSETTS Ila 'i � • • • • l�F+L7 ' � • 5 PLUMBERS AND.,GASFITTERS. j t.' t LICENSEDAS AMAS-,TER PLUMBER ISSUES THE ABOVE LICENSE T0: it JiOHN'P EL,LftS 9 TANG'LEWOOD AVE- Q U) , '9ILLERICA `AAf01821-2422 12977 +05101/14 164354 --W6NWEALTH OF MASSACHUSETTS (. . SHEET METALWORKERS AS AWASTER'UNRESTRICTED ISSUES THE ABOVE LICENSE TO: a; it JOHN P i' >9 TANGLEWOOD 'AVE 4I ►' �' BLLLLR3CA MA 01'821=2422 I � s jL..,.. ., 01'/28/14 104357 { s i • • n; [[irSETT5 — COMI DRIVES OF SOD. dd NUW frJ -.' NONE S48,71 iy8V IANGLCYYWU Aft C BILLERICA, MA 01821 `t I ., 5ou01,29•20ttsev0745-000 r,., CONIMCINWEA - TH OF MASSACHUSETTS _ - P,LU:MBEftS,AND ..GASFIT-Tit , REGISTERED AS A'PLUMBIN0 K P s ISSUES THE ABOVE LICENSE. TO:- l ` # f }' ' JOHNS F EL 1S 2. RIVERS'GO NT.& SER INC 1' BICE 9 �ANGLEWDOD AVEi 9I.LLE,RICA4MA 0,1821-2422 I 2581 05Y0,1%14 164353 • ,Imum ------------------- i.,+ .. COMMONWEALTH OF MASSACHUSETTS Ila 'i � • • • • l�F+L7 ' � • 5 PLUMBERS AND.,GASFITTERS. j t.' t LICENSEDAS AMAS-,TER PLUMBER ISSUES THE ABOVE LICENSE T0: it JiOHN'P EL,LftS 9 TANG'LEWOOD AVE- Q U) , '9ILLERICA `AAf01821-2422 12977 +05101/14 164354 --W6NWEALTH OF MASSACHUSETTS (. . SHEET METALWORKERS AS AWASTER'UNRESTRICTED ISSUES THE ABOVE LICENSE TO: a; it JOHN P i' >9 TANGLEWOOD 'AVE 4I ►' �' BLLLLR3CA MA 01'821=2422 I � s jL..,.. ., 01'/28/14 104357 { s i • • n; [[irSETT5 — COMI DRIVES OF SOD. dd NUW frJ -.' NONE S48,71 iy8V IANGLCYYWU Aft C BILLERICA, MA 01821 `t I ., 5ou01,29•20ttsev0745-000 r,.,