HomeMy WebLinkAboutMiscellaneous - 27 BEACON HILL BOULEVARD 4/30/2018ki 1\
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372
"F.
Date. . §A41-5 . .....
TOWN OF NORTH ANDOVER
PERMIT FOR MECHANICAL INSTALLATION
This certifies that-�� 4C ....................
has permission for mechanical installation ............
in the buildings of .........................
7 North Andover, Mass.
at ............................. I
Fce.��—. Lic. No.�VO .... ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Depi. PINK: Treasurer
F
Commonwealth of Massachusetts
'ate. &F -6—/s Sheet Metal Permit
Estimated Job Cost: CPO
Plans Submitted: YES NO
Business License #
Business Information:
Name: A14�SCA) )/t/AC
Street: 2�L 12r)(�XX
City/Town:/<141/j�/ X /V4
/1 ---, IV,/ <-*
Telephone: 71,1/r 10 L )
Permit #
Permit Fee: $ / 0 �0
Plans Reviewed: YES NO
Applicant License 4
Property Owner / Job Location Information:
Name: 4/&g? 5$4C6ZX�0
Street: 13001-) §
) 71 6IVb
City/Town://, 41,)PoP&,Aq lme
Telephone: 91r 3�_a3 4��L_
Photo I.D. required / Copy of Photo I.D. attached: YES NO
Building Type:
Residential: 1-2 family Vs- Multi -family Condo / Townhouses
Commercial: Office Retail Industrial Educational Institutional
Building Cubic Footage: under 35,000 cu. ft. Jk_ over 35,000 cu. ft.
Sheet metal work to be completed: New Work: % Renovation:
HVAC �9 Metal Roofing Kitchen -Exhaust System _ Chimney / Vents
Provide brief description of work to be done:
M
_/Wolm
Opir Vo &--- alAJ6 /A) Alrfc
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yeg-V No
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability insurance policy U Other type of indemnity [I Bond L1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner Agent F-1
Signature of Owner or Owner's Agent
By checking this boxEl, 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 sheet metal work and installations performed under the permit Issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Progress Inspections
Date Conitnents
Date
Final Inspection
Comrnents
Inspector Signature of Permit Approval
Signature of Licensee
License Number.- /� Y -7-C
Check at www.mass.gov/dpl
Type of License:
By
9 Master
Title
El Master -Restricted
City/Town
Eliourneyperson
Permit #
E]Journeyperson-Restricted
Fee $
F1
Inspector Signature of Permit Approval
Signature of Licensee
License Number.- /� Y -7-C
Check at www.mass.gov/dpl
Sheet Metal Commercial Guidelines I Life Safety I Critical Systems
Inspection Checklist
Yes No NIA
Set of stamped engineering documents and detailed description of
mechanical system to be installed has been provided
All workers performing sheet metal work onsite has valid Massachusetts sheet metal
license
All sheet metal work being performed with pi-opt-,rjoumeyperson-to-apprentice ratios
Fire dampers with access door properly installed and checked for operation
Smoke and combination fire / smoke dampers with access doors properly installed -
actuator chocked for proper operation (May also be verified by fire department during
fire alarm testing)
Duct smoke detectors with access doors properly located
(May also be verified by fire department during fire alarm testing)
Smoke / atrium exhaust systems installed and operation verified
(May also be verified by fire department during fire alarm testing)
Stair pressurization systems installed (where required) and operation verified (May also
be verified by fire department during fire alarm testing)
Grease / kitchen hood exhaust system installed with all seams and connections welded
airtight with properly located cleanouts. Proper c1dj'ances, fire rated enclosures and
pressure testing required..
�.Caintb installed, .0i6m quir�d_ bil �qdibment and du...t., 11
Duct penetrations in fire'rdma- -tvaI3 and flo"6*rs" seal6d'
Metal roofing systems installed watertight -using proper materials and fasteners
Flexible duct runs installed 6'-0" maximum length
Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle
iron
Ductwork / plenum connections sealed substantially airtight
Ductwork insulated by means of extemal covering or internal lining
Volume dampers installed for each supply air branch duct
New/clean - properly sized filters installed (final inspection)
Testing and Balancing report complete (final sign -oft)
Sheet Metal Residential Guidelines / Inspection Checklist
Yes No N/A
Detailed description and sketch of sheet metal system to be installed has
been provided
All workers performing sheet metal work onsite has valid Massachusetts
sheet metal license
All sheet metal work being performed with proper joumeyperson-to-
apprentice ratios
Equipment sized per heating / cooling load calculations
Duct work sized per manual "D" calculations
Bath / shower rooms contain mechanical exhaust fan vented outdoors
Electric dryer exhaust properly installed maximum total run 35'-0",
maximum flexible run 8'-0"
— — Flexible duct runs installed 14'-0" maximum length
Volume dampers installed for each supply air branch duct
Ductwork installed using proper gauges and hangers
Ductwork / plenum connections scaled substantially airtight
DuctwoTk insulated by means of external covering or internal lining
New/clean - properly sized filter installed (final inspection)
Testing and Balancing report complete (final sign-of�
OP ID: PS
CERTIFICATE OF LIABILITY INSURANCE _�ATIE (MM/DD/YYYY)
F 06)03/2014
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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsement(s).
PRODUCER
North Andover Insurance Agency
CONTACT
NAME: Pete Sullivan
E -686-2266 FAX -686-6410
WN., EI), 978 (A/C No): 978
MA. Foster Insurance Services
163 Main St.
E-MAIL
_ADDRESS : psuilivan@fOstersuilivanciroup.com
North Andover, MA 01845
Stephen Sullivan
=ER
ERID,,AMSON-1
INSURERS) AFFORDING COVERAGE NAIC #
-
INSURED Amson ompanles Incorporated
Amson HVAC
INSURERA: LIBERTY MUTUAL INS CO 23043
INSURER 8:
24 Dexter Street
Haverhill, Ma. 01830
INSURER C:
Sean Corcoran
INSURER D:
24 Dexter St
Haverhill, MA 01830
INSURER E:
INSURER F:
Mr-VIbIUN IN11111.111111111:51tH:
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 13 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR _MD-D—L UBFI __P0_L1CYEFF _P6UICY_EXP
LTR TYPE OF INSURANCE POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY1 LIMITS —
GENERAL LIABILITY
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE I X1 OCCUR
CBP8609720
02/06)2014
02/06t2()l 5
EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence) $ 100,000
MED EXP (Any one person) $ 15,000
PERSONAL & ADV INJURY $ 1,000,000
-GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER.
X I POLICY1 I F-1 LOC
PRODUCTS - COMPiOP AGG $ 2,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident) $
BODILY INJURY (Per person)
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE $
lPER ACCIDENT)
HIRED AUTOS
NON -OWNED AUTOS
UMBRELLA LIAB
EXCESS LIAB
HOCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DEDUCTIBLE
I RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y/N ]
OFFICERIMEMBER EXCLUDED'?
(Mandatory in NH)
If yes' describe Linder
N/A
S I OTH-
_1��C �STATU
IM
E L. EACH ACCIDENT
E L. DISEASE - EA EMPLOYE $
E L DISEASE - POLICY LIMIT
1 DESCRIPTION OF OPERATIONS below
OF OPERATIONS/ LOCATIONS /VEHICILES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
A
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
iV 190-209 AGORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
(-A
Location r)-:7
No. Date
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy $
CH
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
24839
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must comDlete all items on this na2e
LOCATION �17 Reve-,W Ili //
Print
nt
MAPNO:�� PARCEL: 0."'ZONN.PriISTRCT:
Historic District yes 0
Machine Shop Village yes no
100 year-old structure ye no
TYPE OF IMPROVEMENT
PROPOSED USE
Resicigntial
Non- Residential
El New Building
0 Addition
El Alteration
likdne family
0 Two or more family
No. of units:
El Industrial
11 Commercial
aWepair, replacement
El Demolition
D Assessory Bldg
F1 Other
El Others:
F ON
F
15W - -
Uvw_&* 51
LWjL7orh7&d_11
1", -, A
DESCRIPTION OF WORK TO BE PERFORMED:
IA1,47f AMI, IAI,111'-YA &,// LAX,
/ I , /V It L001;7�kl oszl�ell
andl 30 ,e4.v 6A',96/--5 A 194hA Jgo-ed-r-
V (Identificatlon Please Type or Print Clearly) -
OWNER: Name: Mr, t lee 5 A14 //Oyo 4-7 Phone:
Address: a7 Selo Ic a" Ai
CONTRACTOR Name: WOr ahilv&o Phone: fV, 579'
Address: ql,� 2. 1�,ItseVIIZI ze� �
Supervisor's Construction License: —EXP. Date: 3
Home Improvement License: Exp. Date: 7f//3
ARCHITECT/ENGI NEER Phone:
Address: Reg. No.
FEE SCHEDULE. BULDINGPERMIr. MOO PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $,41s� eo, C,0 FEE: $
Check No.: / k, �P- Receipt No.:
NOTE: Persons contractin with unregistered contractors do not have a cess I
9 o the guaraa,,fuud
_Ngna, e,q n Wi 7
A
A
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
u Building Permit Application
Li Workers Comp Affidavit
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
Li 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
Li Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (if Applicable)
• Mass check Energy Compliance Report (if Applicable)
• Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
Li Certified Proposed Plot Plan
Ei Photo of H.I.C. And C.S.L. Licenses
E3 Workers Comp Affidavit
E3 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
L3 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
Doe: Doe.Building Permit Revised 200 Smi
-I
Plans Submitted El Plans Waived El Certified Plot Plan El Stamped Plans El
TYPE OF SEWERAGE DISPOSAL
Public Sewer El
Tanning/Massage/Body Art
Sw"mn'ng Pools El
Well 0
Tobacco Sales
Food Packaging/Sales D
Private (septic tank, etc. [I
Permanent Dumpster on Site El
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATEAPPROVED
PLANNING & DEVELOPMENT El El
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Reviewed on Siqnature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: —Zoning Decision/receipt submitted yes
Planning Board Decision:
.Comments
Conservation Decision: Comments
Water & Sewer Con nection/signature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes -No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$l 000 fine
NU I tZS and VATA — (For clepartment use
13 Notified for pickup - Date
Doc:.Building Permit Revised 2011 Junelmi
Mike SW11-van - Roo-fing Contractor
919,Eas! Broadway
Hove,-hO, Mf4 01830
(978) 374-]319
- c --;--q .7 --,- 1 n -forrvi a tioz Contractor T.jnforrilation.
L1, Iq
Co. pa�,y Na.c
A4. ke- 9j A�i 4
Street Address (do net P=, Office Box addre,ss)
C.r�ractor/ Salesperson/ Owner Na -me
a-7 ae 41-0;1 Uil I
I m I k--- 5(, //ij, 4,-7
cityrro',n State Z,p Cod e
Busint,ss Address (must include a street address)
/V . hn boe"I IV A ,
?/ '? 'F � Be o &/ W -ik ____
DaytimePhorte E'e.i.gpl
City,�Town State Zfp Code
og -7,q q 4 q -5-q
eq3e
Maih�rc Address (It dYferdat From above)
B.ittesc Poor, FFederaJ Employer DD or S,S.Numbar
i,p,
:3 1-711 j
T'he Contractor agrees to do the following work forth e Homeowner.
(De,scribe in detail the-ork to completed, speci��, the typr, bound, met garadc of materials to heused, weadditional shd�ets ifreaessaryw)
-"4 &14 howe 4'"'W 1,44" j jt4,,/ /WU/J�vj
3 4 40
a vewe Hve-c- I k -skovle-s dfW6,e 1"Voij
54_"j,4, g&/1 .8# $&M .4j,)p ej
Ice w4r # j e,
Required Permits - The following building permits are required Proposed Start and Completion Schedule - The following schedule Aill
and will be secured by the contractor as the homeowner's agent- be adhered to Latless circurogwces; beyond the contractor's control arise
(Owners who seecure their own permits will be
efeluded from the Gumntv Fund provisions of
lVa /'Date whea contractor will begin contracted work
h1GL cb apter 142A.) N
jW _4�11 Date whea com:-acted work will be substantially completed
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work, famish the material and labor specified above for the total sum 20S i tee'e'a
Payments will be made according to the following schedule:
S kWQ 1_ Upon Signing Contract (not to exceed 1/3 of the total contiact price -or the cost ofspecial order items, wliicb�ver is greater)
.S If 417 4 by or upon completion of
S. by _j crtiponcompleti000f_
S uponcompletionoftneroatract. (Law forbids demanding full payment until contract is completed to both par-Ly's satisfaction)
The following material/equipment must be special S to be paid for
ordered before the contracted work bnouns in order
to meet the completion schedule.(� S to be paid for
NOTES (')including all finance charges (`4:) Law requires that my deposit or down -payment required by the contractor before work begins may
not exceed the greale, of (a) one-third ofthe total contract price or (b) the actual cost ofeny special equipment or custom made material
which must be special ordered in advance to meet the completion schedule
Expre,ss Warntv - Isan cxnress is-n-arry being provided b,, the contractor? f�o 0 Yes (all terms of the -irrint, m ust be attach ed to the con tract)
Subcontractors -The contracto, agrees to be solely responsible for completion of the work described regardless of die actions of any third
party1subcoutraGlor utilized by 1ho-contracroi. The contractor further agrees to be solely responsible for all payments to all Subcoutcactot5 for
materials and labor urtler this aaeem'emt
Contract Acceptznce - Upon signing, diis,docament becomes a binding contract under law. Unless otherwise noted within this document, the
con tract sh all not imply that any hear or other security interest has been placed on the residence- Review the following Gau dons and notices
carefully before signing this contract.
Don't be p, es3ured into signing the contract. Take time to read and fully traderstand it. Ask questions if sobtething is unclear.
Make sure the contacto- has a valid Home IMDrOvement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered v�ith the Director ofHome TMprovement Contractor Registration. You may incuire about contractor
registration by writing to the Director at 10 Park Pl" Room 5170, Roston, MA 02116 or by calling 617-M-87/87 or ESS -283-3757.
Does die comn actor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to
see a copy ofa'�proofofirisurance document.
Know your rights and responsibilities. Read the Important Information on the reverse side ofthJs form and get a cop), ofthe Consumer
Guide to the Home ImPrcvement Contractor Law.
You may cancel tilts agreement d it has been siped at a place other thm the contractor's normal place of business, provided you not:Yy the
contractor in vmfing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later -,ban midnight of the
third business day followrinR Lhc signing of this agrecincot. See the attached notice ofcaicellabon form for an explanation of this right.
DO NOT SIGN THIS CONTRA -CT 'IF THEPE ARE ANY BLANK SPACES!!!
T,,oid,,6c,Jco�iesorLhtco,=amztb,compi,�d and sip,d. Caeco-shouddgot,thelsom—mer. The other dop�, sLo,ld oe JL,p[ by the coonc-
HcWwuer's Siga��,
Date
, P
10yXa4i, 1� -
Contractor's Signatilre If
Date
Conti -actor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an
alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to 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 mutually agree in advance that in the event the contractor has a dispute
concerning (his contract, the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shatl be required
to s bmit o such arbitration as provided In Massachusetts General Laws, chapter 142A.
—Um"'A, - 9�� '. / jwcrl-a
IfQwkwrier's SWture Contractor's Signature
NOTICE: The signatures of the par -ties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowrier's rights under the Home Improvement Contractor Law (MGL chapter 142A) 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 froin 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 workmanlike 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 carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the 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 you have
questions about your consumer/homeoAmer rights, contact the Consumer.hifonnation Hotline (listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked 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 10 by botla parties. Coatracted work may not begin unffl both parties 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 firiancially insecure, the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer Tights, 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 Park Plaza, Room 5170, Boston, MA 02116
617-973-878T, 888-283-3757 or visit the OCABR website athar,-/'\� �ocaihnl
If you want to verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor regloiration component of' -he Home Improvement Contractor Law, contact:
Director of Home Irnprovement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza, Room 5170, Boston, MA 02116
617-973-8787, 888-283-3757 or visit the HIC website at �n,:
Go online to view the status of a Home Improvement Contractor's Registration:
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
508-652-4800, 508-755-2548 or 413-734-3114
Venion 2.1 - 11/22!2010
ACCA?& CERTIFICATE OF LIABILITY INSURANCE
(MM/DIYYYYY)
7
A
11/4/11
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(S), AuTHOPJZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsemengs).
PRODUCER
Barry J. Kittredge Ins Agency
81 South Main Street
PO Box 5206
CONTACT
NAME: Dana Moody
PH
WN,E,tj� (978) 374-8400 lffAIX�No) (978) 3-73-3360
E-MAIL
-ADDRESS, aana@kittredqeinsurance.com
FFQRDING COVERAGE
JA_ NAIC#
Bradford, MA 01835
INSURERA: Western World Ins. Co_
INSURED
Michael J Sullivan Roofing, LL
919 East Broadway
Haverhill, MA 01830
INSURER B:
INSURERC:
WSURER D
_1NSUFtER E:
INSURER r:
UOVtKAUtb CERTIFICATE N UMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT —THE POLICIES OF INSURANCE LIS FED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
NOTW!TH STAN DING ANN RFQ.1_ IIPFMENT, TFIR1\1 OR CONF)ITION, OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CEW�IFII]ATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANDCONDITIONS OFSUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR1 JADD SUBR� UCY EFF P OU CY EXP
TYPE OF INSURANCE R POUCY NUMBER (..
LTR IN Ll POIDDIYYYY (MMIDDYYYY) LIMITS
A
- GENERALLIABIUTY
X COMMERCIAL GENE RAL LIABILITY
NPP1304499
4/28/11
4/28/12
EACH OCCURRENCE $ 300 —000
_DAWGETO
2RE $ 50,000
MED EXP (Anyone person) $ 5,000
CLAIMS -MADE X OCCUR
PERSONAL-& ADVINJURY $ 300,000
GENERAL AGGREGATE $ 600.000
GEN'L AGGREGATE LIMITAPPLIES PER
POLICY F ]m PRO- LOG
I ECT
PRODUCTS - COMPIOP AGG $ 600,000
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(E a accident) $
—person)
ANYAUTO
BODILY INJURY (Per
ALLOWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident) $
NON-OVVNED
I HIREDAUTOS — AUTOS
PE RTY D/WLA GE
_(Peraccident) $
:$
UMB RE LIA LIAB
F R
EACH OCCURRENCE
EXCESS LIAB
. CLAIMS -MADE
AGG RE GATE $
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORiPARTNER/EXECUTIVE
OFFICE RIME MBER FXCL UD E D?
(Mandatory in NH)
Ues. describe under
NIA
WC STATU- OTH_
____L_TORY I MiIS1_LER___
E.L. EACH ACCIDENT $
E.L DISEASE -EAEMPLOYEE� S
E.L. DISEASE - POLICY LIMIT $
1) SCRIPTION OF OPERATIONS belo�
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Affach ACORD 101, Additional Re"rks Schedule, if more space is requi red)
Roofing
CERTIFICATE HOLDER CANCELLATION
Halloran
27 Beacon Hill Rd
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
No. Andover, MA 01845
AUTH���
I
,/, (D f§88-2010 ACORD CORP6RA All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo ar /registered marks of ACORD
Phone: Fax: E -Mail:
HOME IMPROVEMENT CONTRACTOR
Registration: .118384
Type:
Expiration: .317/2013 Inaividual
L J. SULLIVAW�-�---j-----'
MICHAEL S U L L I
.. �;q
919 E. BROADWAY
HAVERHILL, MA 01 no
Undersecretary
Nla-smichusetts - Npartment of' plif)jic S�jt'et
Board of Buildin-� Regulations it)(] Standard
Construction Supervisor Special'ty License
License: CS SL 98853
Restricted to: RF
MICHAEL SULLIVAN
919 EAST BROADWAY
HAVERHILL, MA 01830
Expiration: 5119/2013
-: T 14224
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ACMU
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
44 0 /,.
This certifies that ... 2 ............................ ....................................................
rM ....
has permission to perfo ..................... . .............. L ...........................
. . ....... ........ ...... ...............
wiring in the building of ...... J.-7. et -,5.c. 61v..1711'.11 ..... 1?1041
at............................................................... * .......... , North Andover, Mass.
fy .. .......... ........ ................. ......
Fee.. 3.5( ?0.. Uc. No. A7 . .. 1-11�
CAL INSPECMR
Check #
9371
Commonwealth of Massachusetts Official Use Only
Department of Fire services Permit No.
rm
Focrctipancy
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
Eev. 1/07J 0-avrblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL
All work to be performed in accordance with the Massachusetts Electrical Code (M C), 527 CMR 12.00 WORK
(PLEASE PRW EV BX OR YTPEALL flVF0P6" TJOA9
Date:
City or Town of. NORTH ANDOVIER To the JnApecto?lof Wires:
By this application the undenigned ves notice of his Performthe electrical work described below.
Location (Street & Number) C-0 'Y Ilt
Owner or Tenant -'( u r
Owner's Address P -L -C Telephone No.
ft
Is this permit in conjuncti a�uilding permit? yes (Check Appropriate Box)
Purpose of Building
Eldsting Service Amps Utility Authorization No.
New Service //d '1226 Volts -Overhead UndgrdE] No. of Meters
AMPS --!—Volts Overhead UndgrdE] - No. of Meters
Number of Feeders and-Amplacity
Location and Nature of Proposed Ellect-ric-111 Work: 1) — — — I — — — — — —
6
V
-::�__C-111111don �ofthe f �114
fLLhe ollom4n table may be waiv b
_y the Inspector f Wires.
No. of Recessed Luminaires No. of Ceil.-Susl (paddle) F, s 111J. U1 Total 0
No. of Laminaire Outlets No. of Hot Tubs Transformers KVA
Generators KVA
No. of Linninai
res S r7 l�licy Ig g
id. LJ Ba e nits
No. of Receptacle Outlets No. of on Burners FM A1-kRMS
No. of Switches of Zones
No. of Gas Burners ,—tecti-
No. of o x lt-al d—
NO. of Ranges No. of Air Cond otal Initiating Devices
Tons No. of Alerting Devices
No. of Waste Disposers eat Pump ..mb.er Tons.- KW.-- o. of S ! -Con i ed
Totals: ........ Detection/Alertin a, Devices.
No. of Dishwashers Space/Area Heating KW Municij:i`-��_--
Local [] al Other
No. of Dryers Co ection
Heating Appliances KW Security Systems. -
140. 01 water No. of No. of Devices or Equivallent
Heaters KW 0. of Data Wiring:
No. Hydromassage Bathtubs signs Ballast No. of Devices OLEquivalent
No. of Motors Total HP Telec!l'�l�',Il��1!1,�1!11''�l''li�''I'll!lll''l�'!'!!I,'I��Iiil'l�l,�l!''Ilii� I iring:
JOTHER: of Devices o E t
Estimated Value of Electrical Work: Attach additional detail ifd ire , or as required by the Inspector of Wires.
Work to StarL. -- . (When required by municipal policy.)
Inspections to be requested iii accordance with MEC Rule 10, and upon completion.
INSURANCi-COVERAGE. Unless waived by the Owner, no Permit for the performance of electrical work may issue unless
the licensee provides proof of hability insurance including I, 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 [I BOND E3 OTHER 0 (Specify)
I cert�&, under the pains andpenaldes ofperjury, that the informadon on this applicayon is true an . d complete,
FIRM NAME:
Licensee: 7 LIC. NO.:
ep,.,, 1,),r, Signature
(�rapplicable, el W LIC. NO.:
?MPt in the license number line.) 4o, L
Address: Z/, Bus. Tel. No.:')I?
*Per M.G.L c. 147, s. 57 ��i 0 AIL Tel. No.: 2CLZIL �p 9
-61, security work requires Departrmn ofpablic Safety 'IS" 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) 13 owner
Owner/Agent owner*s a-tnt.
Signature C�
Telephone No._ PE"IT FEE S 9,5—o D
The Commonwealth of Massachusetts
Department ofl'ndustrial Accidents
Office of Investigations
Washington Street
Boston,, AM 02111
www-massgovldia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electridans/Plumbers
Applicant Information Please Print Legibiv
Name (Business/OrganizatiorAndividual): :�6S�,_
Address:_.
City/State/Zip: &�,
�P,, U WO Phone #:
Are you an employer? Check the appropriate box:
1. 0 1 am a employer with _
4. 1 am a general contractor and I
erapb (full and/or part-time).*
have hired the sub -contractors
2. �aj� ayseces proprietor or partner-
listed on the attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5- We are a corporation and its
required.]
3. 0 1 am a homeowner doing all work
officers have exercised their
right Of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees- [No Workers,
-A
COMP. msurance required.)
Type of project (required):
6. New construction
7. Remodeling
8. Demolition
9. Building addition
10 -El Electrical repairs or additions
11 - F Plumbing repairs or additions
12 -0 Roof repairs
13 -El Other
t �A — -_-W IM UUL Me StMOM M.101V Eno " , - -W kers� cy
140 - - !"u-9 thett —. -ompensation pol: informa
co"M affidavit indicating they are doing all wOrkand th- hire outside contractors must submit a new affidavit indicating such.
who slabluitthis
lContm.t.. that check this box must attached an additional sheet showing the name ofthe sub -contractors; and their workers, comp. policy information,
I am an emPlOyer that isPrOviding wOrkerS'COmpensation ins-urancefor my employees. Below is thep0licy andiob site
informadom
Insurance Company Name:
Policy # or Self -ins. Lic. it:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c pajnsdndp� aides OfPeriurY that the information provided above is true and correct
7�kl)76 -77 1 J -
M111ALWANIM
use only. Do not write in this area, to be comp
leted by city or town officiaL
City or Town:
Permit/License #
3d/,/6
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other t,
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, associatior� 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 coirupliance 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 completzly, 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 th civ, or town that eque
Me y . , , the applicationfor the pernait or license is being — sted, not +he 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 applicanL
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 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigrations
600 Washinp-ton Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8 77 -MASSA -FE
Revised 5-26-05 Fax # 617-727-7749
www.mass-gov/dia
,ORTPI
SS4
Date.....................
TOWN 00 NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
1'2-
................
This certifies that . . . - -/— . .. 4"*', * * * ' * — * * * ' ' * * * * * ' —
has permission for gas installation
in the buildings of
.............................
..... North Andover, Mass.
Fee Lic. No..16 10�
GAS INSPE�CTOAI
ZI
Check #
7193
4
MASSACHUSETTS UNUFORMAPPLICATUNFORPERMrrT)C)DO GAS FrrnNG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations -2, ec, c o ^ W, I
Permit ft I F3
'41 4�j /'A k Owner's Name 3—ir�e Amount
New Renovation Replacement rl Plans Submitted
(Print or type) 1� I
Name-- 1A
Address 8 �� D j � 00 8- ISI,
-77 A Q,� e,, A c., r D �s ,
Vuslnessl elephone i�:l 3 L/1
wl�ll
Name of Licensed Plumber or Gas Fitter I CL--"%- 3 (-9
Check one: Certificate Installing Company
Corp.
V p er.
F VCO
irn
INSURANCE COVERAGE Chec
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yes, ple . cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity E] Bond
0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
— Y — I.Y IaL U L11F, UZLCIIIN WIU 1111UHIRRIU11i nave suormuea �or enterect) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform5d under Pern)0sued for this application will be in
compliance with all pertinent provisions of the Massachusetts State/t&
JC-Aean Ch 142 of the General Laws.
7- 916r
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed/lu rber Or Gas Fitter
Plumber 95- (Q �;-
Gas Fitter License Number
Master
Joumeyman
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SUB-BASEM ENT
B A S E M E N T
IST. F L 0 0 R
2 N D . F L 0 0 R
3RD. F L 0 0 R
4TH. F L 0 0 R
5TH. F L 0 0 R
6 T H F L 0 0 R
7 T H F L 0 0 R
ST H. F L 0 0 R
(Print or type) 1� I
Name-- 1A
Address 8 �� D j � 00 8- ISI,
-77 A Q,� e,, A c., r D �s ,
Vuslnessl elephone i�:l 3 L/1
wl�ll
Name of Licensed Plumber or Gas Fitter I CL--"%- 3 (-9
Check one: Certificate Installing Company
Corp.
V p er.
F VCO
irn
INSURANCE COVERAGE Chec
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yes, ple . cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity E] Bond
0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
— Y — I.Y IaL U L11F, UZLCIIIN WIU 1111UHIRRIU11i nave suormuea �or enterect) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perform5d under Pern)0sued for this application will be in
compliance with all pertinent provisions of the Massachusetts State/t&
JC-Aean Ch 142 of the General Laws.
7- 916r
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed/lu rber Or Gas Fitter
Plumber 95- (Q �;-
Gas Fitter License Number
Master
Joumeyman
.,4
The Commonwealth of Massachusetts
Department Of Lndustrial Accidents
Office of Invesfigations
.600 Washington Street
Boston, AM 02111
www-mass.,-,,ov1dia
Workers' COMPensation Insurance Affidavit: Builders/Contractors/Eler-tridans/Plumbers
nniii-ant
Name (Business/Organizafion/Individual):
Address: OS a
City/State/ZiPJ4(AoJ(,2_ /qct 3c� [ -0
Phone
Type of project (required):
6. [] New construction
7.' F011Remodeling
8. Demolition
9- Building addition
10-D Electrical repairs orad(litions
I I - 13 Plumbing repairs or additions
12.[] Roof repairs
13. [1 Other
comp-onsMon policy m1ormatlan.
Homeowners who submit this affidavit indicating they am doing all work and then hire outside contracton must submit a new affidavit indicating such.
:COntractDrs that check tins box must attached an additional sheet showing the, riame of the sub -contractors and their workers' coMP. policy information.
lam an employer that isproviding workers'compensation Inisarancefor my employee& Below is thepoliQ, andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. ��Do b Y� Expiration Date: I
Job Site Address:O JeQ cp^ Ff (VJ,
City/State/Zip:_1 1�0 I a-� A
Artach a copy the workers' compensation policy declaration page (showing the policy number and expirati.. i.* -
'P.
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 irnprisonrneat� 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 D1A for insurance coverage verification.
i ao nereby c 01117
r� n . �11 11PIPirndpenalfies ofperjury that the information Provided above is true and correct.
� 1-f? _5__ q2_3
OffIcial use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License 1i
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
It- )- F - lrz-)
Contact Person:
Phone #:
Axe you an employer? Check the appropriate boxi
I I am a employer with 0
4. [1 1 am a general contractor and I
employees (full and/or part-time).*
2.[] 1 am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insuranc
[No workers' comp. insurance
5- 0 We are a corporation ane*
d its
requ ired.]
3. F� I am a homeowner doing all work
Officers have exercised their
right of exemption MGL
Myself [No workers' comp.
per
c. 152, § 1 (4), and we have no
insurance required.] t
employees. [Noworkers'
cOmP- insurance required.]
M, aplicaut that checks box #,l must alsc, fill, oult the --couUn nt�OV2 gL6O%�,L.f, __
Type of project (required):
6. [] New construction
7.' F011Remodeling
8. Demolition
9- Building addition
10-D Electrical repairs orad(litions
I I - 13 Plumbing repairs or additions
12.[] Roof repairs
13. [1 Other
comp-onsMon policy m1ormatlan.
Homeowners who submit this affidavit indicating they am doing all work and then hire outside contracton must submit a new affidavit indicating such.
:COntractDrs that check tins box must attached an additional sheet showing the, riame of the sub -contractors and their workers' coMP. policy information.
lam an employer that isproviding workers'compensation Inisarancefor my employee& Below is thepoliQ, andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. ��Do b Y� Expiration Date: I
Job Site Address:O JeQ cp^ Ff (VJ,
City/State/Zip:_1 1�0 I a-� A
Artach a copy the workers' compensation policy declaration page (showing the policy number and expirati.. i.* -
'P.
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 irnprisonrneat� 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 D1A for insurance coverage verification.
i ao nereby c 01117
r� n . �11 11PIPirndpenalfies ofperjury that the information Provided above is true and correct.
� 1-f? _5__ q2_3
OffIcial use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License 1i
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
It- )- F - lrz-)
Contact Person:
Phone #:
1�
Information aa d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this st atate, an employee is defined as "...every p=rson in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, assooization, 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 ox- other legal entity, employing employees. However the
owner of a dwelling house having not more. than three apartaxents and who resides therein, or.the o.ccupant of the
dwelling house of another who employs persons to do maintc3aance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not bec�ause of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or llocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to a-onstruct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coinpliance with the insurance coverage required."
AdditionaDy, MGL chapter 152, §25C(7) states "Neither the c�;ormnonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work untE acceptable evidence of compliance with the insurance
requimments of this chapter have been presented to the cont-aLcting authority."
Applicants
Please fill crut 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 numiber(s) along with their cerdficate(g) 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 ronfirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be rctLrncd to the city or, town that the apiplicaddor, ffor the pernait or license is being request—ed, not the Department of
Industrial Accidents. Should you have any questions regardiixg the law or if you are required to obtain a workers'
compensation policy, please call the Department at the numb5r 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 I egibly. 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 p=miVhcmse number which will be used as a ref6rence 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 offici�lly 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 permaits or license&. A new affidavit must be filled out each
yew. 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.them.k. you in advanr-e for your cooperntior and should you have. any questions,
please do not hesitate to give us a call.
The Department's address, tzlephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office Gf Investigations
600 Washington strwt
Boston, MA 02111
Tel. # 617-727-4900 e.% -t 4-06 or 1-8 77 -MAS SAFE
Revised 5-26-05 Fax 4 617-727-7749
vmrw.m&&s..-gov/dia
4:2/
Date ...... .......
,40RT#1
1 6 t- TOWN OF NORTH ANDOVER
o
PERMIT FOR GAS INSTALLATION
SS CHUS
This certifies that . . .
........................................
has permission for gas installation Al ...............
,in the buildings of .
............
at
No)rth Andover, Mass.
Feek ..... Lic. If ...........
ldASINSPECPA
Check #
3 6 � 5
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO GASFITTING
(Print or Type)
T ype of Occupari�(y
New Renovation C] Replacement 0 tans SubmItted: YesC] No Cj
Installing Company Name_,eL/4/-�7a,-,� (24-11 Check one: Certfficate
Address—/ 2-5 Z-4 /(�-_ SA,�,jCe_ e5 / le 0 Corporation
-go � A6,%7,7 -loo C] Partnership
�Buslness Telephone Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
yes 0 No 1-1
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liabillity Insurance policy C1 Other brpe of Indemnity 0 Bond 0
OWNER'S,INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement
Check one:
Signature of Owner or Owner's Agent OwnerO Agent 0
I hereby cer* 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 the permit issued for this application vAll be in compliance with all
pertkwt provisions of the Massachusetts State Gas Code and Chapter 142 of General Lms.
T5 of License: I A- -..4
1 0WqV=— ivwlek4l�
Pkimbef Pnatbre of Licensed Plumber or Gas Frtter
4
Two Gasfitter
M I
aster License Number ZcT-5
Journeyman
mass.
Date -7Z7-0 ;W01 Permit #-40q4
Building Location
22 ; 6 41d
Owner's Name
/6(1 e er—
T ype of Occupari�(y
New Renovation C] Replacement 0 tans SubmItted: YesC] No Cj
Installing Company Name_,eL/4/-�7a,-,� (24-11 Check one: Certfficate
Address—/ 2-5 Z-4 /(�-_ SA,�,jCe_ e5 / le 0 Corporation
-go � A6,%7,7 -loo C] Partnership
�Buslness Telephone Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
yes 0 No 1-1
If you have checked Yes, please indicate the type coverage by checking the appropriate box
A liabillity Insurance policy C1 Other brpe of Indemnity 0 Bond 0
OWNER'S,INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement
Check one:
Signature of Owner or Owner's Agent OwnerO Agent 0
I hereby cer* 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 the permit issued for this application vAll be in compliance with all
pertkwt provisions of the Massachusetts State Gas Code and Chapter 142 of General Lms.
T5 of License: I A- -..4
1 0WqV=— ivwlek4l�
Pkimbef Pnatbre of Licensed Plumber or Gas Frtter
4
Two Gasfitter
M I
aster License Number ZcT-5
Journeyman
'41
L�
Location
44,5
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # Z,1411 r--
18873
"—Building InspectlK
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
OR DEMOLISH
APPLICATION TO CONSTRUCT W A ONE OR TWO FAMILY DWELLING
K X
E
BUILDING PERMIT NUMBER. DATE ISSUED:
SIGNATURE:
Building Commissio r of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address: C�i� 1—
1.2 Assessm Map and Parcel Number:
14z"tL 3L,_0
,,"-
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
ZoningDistrid Proposed Use
Lot Area (sf) Frontage (ft)
1.6 BIJUDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Repired Provided
�red Provided
1.7 Water Supply NLIaLC.40. 54) 1.5. Flood Zone Information:
1.8 SewerWDispoul System:
- Public 0 Prwm 0 zone Outside Flood Zone 0
Municipal 0 On Site Disposal System 0
SECIION 2 -PROPERTY OWNERSHIP/AUTHORIZED AG__ ENT
Historic District: Yes No
2.1 Owner of Recond
94W YlLt�-L 6LUD
t) Address for Service:
Lww"P
7 (� -) S 33'7 3
tSij�ia—tur'e Telephone
.2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Appficablc 0
Rt(c, J 27
U.1,60
Licens�d Construction Supervisor:
License Number
Address
2---D
'?�
'�
Expiration Date
Sign_a1M-_ \ Telephone
3.2 Registered Home Improvement ConftctDr
Not Applicable 0
CompanyName
Registration Number
y
Add
E*mfion Date
Signati;r—c Telephone
Ma
M
X
z
0
0
z
M
90
0
I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 § 25c(6) I
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 buildiggpermit.
Signed affidavit Attached Yes ....... (4," No ....... 0
SECTION 5 Description o Proposed Work (cheeck applicable)
New Construction 0
Existing Building [I
Repair(s)
Alterations(s)_ 0 1
Addition 0
Accessory Bldg. [I
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
-z
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
us!
LAL�' "0
�M
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
'-:5- C93
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize 12 b C- 6-� to act on
My behalf, in #i=-en�elative K-w-o-
1]Z>author'zed by this building pennit application.
!�� I 'L I , 'f J-0'r—
Signature of O;�ire-r Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I'—P 0 0�?� 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
Print NpnC----)
Signature of Ovaher/Aient
NO. OF STORIES
Date
SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS I 9T
2ND 3RD
SPAN
DINIENSIONS OF SELLS
DIMENSIONS OF POSTS
DIMFNSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CHNINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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n�l Board of Buflding Regulatiogs aud Standards
EMENT CONTRACTOR
HOMEIMPROV
Reqlslt�" 106620
U0IltltJW,�ffW24/2006
d' teCorporation
—T IW
Ki
-
RICHARD FLUEt.-,�C'6.,i��R,'A'6i-rN'G"IINC.
e-)
Richard Fluet
02 Bridle Path Lane,,,
Methuen, MA 61844 Administrator
BO
ARD�O -DI GU`l:AflONS'J'
fR-UCTI- 0 WSOR
�.'1-16dhse: CONS E
56
N-umbrer,tS,. 050710
I rth d-atd-
L
1:2721
Fe ",q 472 Tr. n
r r
Q- 4 tem-
a—
RIGHA
RCrA FLUE
T-.
162 6AIDLE K
-d18
--- - ---- - -
J
The Commonwealth ofVlassachusetts
Department of hidustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 021 H
www.mass.-ov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name MUS611CNS/01'�"alliZi ItiO11/111di'lidUal): t jc-tj 17---1
,-? L-07 C-0
Address: 10 4— 0- Y?,,� 0
City; State/Zip: Vl--A- G::�(W— k414 Otgtt �_Phone 4: 9 -? 0 (_ � f__ _k)f 6
Are you an employer? Check the appropriate box:
I.M�l arn a employer with 4
/F—ernployees
4. [1 1 arn a general contractor and I
(full and/or Ilart-time)."
have hired the sub -contractors
2.E1 I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
'These sub -contractors have
working for me in any capacity.
workers' comp. insurance,
[No workers' cornp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
I am a homeowner doing all Aork
right of exemption per MGL
myself. [No workers' comp,
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n New construction
7. ARemodeling
e [] Demolition
9. [] Building addition
10.F
I Electrical repairs or additions
II.El Plumbing repairs or additions
12.E] Roof repairs
13.0 Other
I 'Any applicant that checks box # I must also fill out the section Wow showing their workers' compensation policy infornimion.
Homeowners Aho submit this atridavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating �uch.
Contractors that check this box niust attached ,in additional sheet showing the nanic orthe sub -contractors and their workers',conip. policy information.
I am (in employer that is providing workers' compensation insurancefor iny employees. Below is lite policy andjob site
information.
Insurance Company Name:
Policy .4 or Self -ins. Lic. 4: UILJ C-, �7 C) Expiration
Job Site Address: City/State/Zip:_
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or onemyear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of Lip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerqo,-�e pains ymf —pe—n—aftrils, (Y*perjury Mat the inji)rmation provilleil above is true and correct.
9 _? �? �? �__
lhone 1:
.ficial use only. Do not ivrite in 1his area, to be completed b city or lown qUicial
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#:
Location -
No. Date
TOWN OF NORTH ANDOVER
Check #
147 - 5
Building InspectC57,
I
aim so
Certificate of Occupancy
$
*Area o
CHU
Building/Frame Permit Fee
$
0.
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
147 - 5
Building InspectC57,
I
TION TO CONSTRUCT
BUILDING PERNUT NUMBER:
SIGNATURF-
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY
DATE ISSUED' '
c2i —
Bullchng Confawslo Date
SECTION I- SITE INFORMATION
Property Address: 1.2 Assessors Map and Parcel Number:
�00covl, 1W kd
Map Number Parcel Number
1.3 Zoning Wormation: 1.4 Property Dimensions:
4ai�c—t Proposed Use___ Lot Area (st) Frontage (fl)
:.6 BURDING SETBACKS (ft)
Front Yard Side Yard Re" Yard
Required I Provide Required . I Provided Rmuired Provided
.7 Watar Supply hCG.I_C.40_ 5 _,4) Zone 1.5. Flod Z,= Wam3atjon: 1.9 3--p D4 -A Sy--
ublic 0 pfivaft 0 Otaidu F" Zone 0 Munkipal 0 On Site DisposJ System 0
'ECTION 2 PROPERTY OWNERSHIPIAUTHORIZED AGENT
10 r of ReWrd
, , . 'To k V� BU
lam. (Pnhtj-
ignature
2 Owner of Record:
Name Print
27
Address for Service:
Address for Service:
A- JLJLSJ14 i - U014YfRUCTION SERVICES
Licens struct, S
j cl�� on u7isor: Not Applicable 0
CX) C(
- L ((a�, V--
ensed Construction Supervisor: n;WYAG
License Number
!�37 (C, -C( ". _FC4fd 10 k92 I
Iress )oo7
4 2o (2
Expiration/ Date
ialure Telephone
Zegistered Home —Improvement Contractor
pany Name C ; e— - ( C) ( , T�A-e rcj� z
ess
ture, Telephone
Not Applicable 0
Registration Number
2- j 17 12(D,,-)
Expiration Date'
I
W211
ww--�
55
16
SECTION 4 - WORKERS CO]UPE-NSATION (KG.L C 152 § 25c(6) -1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuanc-c of the building permit -
Si ned afEdavit Attached Yes ....... 0 No ....... 0
SECTION 5 De- Prolmsed Work (check A appricable T --
New Construction U Existing Building U Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. 0 Demolition El Other 0 Specify
Brief Description of Proposed Work:
16,ko
oac Q(A, (\V\ 2-W, (), �
LO ya6j< J ex -T
eu
or, 0,9-f
N P yAwrd-t-D�41r &I �( O&W
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
ftsft�alod Cost (Dollar) to be I- Agrat'li.,
Estimated-�
C rmit applicant M
Building
ng
(a) Building Permit Fee
Multiplier
Ice
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumb'
I Building Pmnit fee (a) x (b)
4 Mechanical HVAC
AC
OUR
5. Fire Protection
t ti 0
1
6 Total 1+2+3+4+5
"heck Number
SECTION 7a OWNER AVMORIzATION TO BE COMPLETED WIMN
OWNERS AG r og �pATRAcToR
APPLIES FOR BUILDING PERART
as Own,
Hereby authorize
My behalf, in all matters relative to work authorized by this building permit application.
SiEnature of Owner Date
SECTION 7b OWNER/AUTHORIZFD AGENT DECLARATION
zed Agent �f subject property
to act on
-1 as OwnerlAutholized 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
rrint Name
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Cornpensation Insurance Affidavit
—7 Location: k I VO\
Ci!Y RC4 Phone
F-1 I am a homeowner performing all work myself.
4� I am a sole proprietor and have no one working in any capacity
E-1 I am an employer providing workers' compensation for my employees working on this job.
Compan name:
Address
Cily: Phone
Insurance -Co..
Coln PaLiy.name.
Address
Cik. Phonet
F —6 -.-: . as eq- - - -. 2 : - MGIL 152 C*n leadfoi th6 Imposition of-criminall p-walties ofa fine lip to $1,5w.'00
ai reto secure coverage r uIred under S6ctlon Mor
and/or one years' imprisonrTiL-ntAs-Well-as-6iOlpenattiesln-ffi6lomnf-a�8.]!QP:.WVj.RK-ORE)ER.aad..a:fine.cfA$IDO-M-aAay-agairtstme. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the MA for coverage verification.
I do hereby certify uncLer the pat nalNes of peijury that the information provided above is true and correct.
7nN
(P 12-b (0
Signature Date
Print name vc)� e Le i3la Vx 0- Rhone.# q79-352- 6317o
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
EJ Building Dept
nCheck if immediate response is required Licensing Board
Selectman's Office
Contact person: Phone E] Health Department
Other
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Town of North Andover
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Building Department 0
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax. (978) 68 8-9542
4rED P-9" C
DEBRIS DISPOSAL FORM
In accordance with the provisions.of MGL c 40 s 54, a'nd.a condition of
Building permit. 9 - the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c I'l, sl 56&
The debris will be disposed of in /at:
ro torA.,
Facility location
Sign*aturof Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for t lhi's
project through the Office of the Building Inspector.
Location C2 9 be8)CO3-j UA� 8W *1 ILq
No. DOS— Date
TOWN OF NORTH ANDOVER
00
Certificate of occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
CH
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
—h (I
Building inspector
120/46
01/12199 14:39 30. 00 PAID
Div. Public
Works
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Town of North Andover ORT4
OFFICE OF
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COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
WUI-LkM 1. SCOT7 SAC ustl�
Dirraor
In accordance with the provisions 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 NIGL c I 11, S 15'OA.
The dcbris Nvill be disposed of']W
In ' - L-- & - 1911"As 3J rT
f F ity
(Location o a
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Signatur� 0-�Pumit AllpficanF
1` 9 Ell
Date
NOTE' Demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector,
r,
BOARD OF APPEALS 689-9541 BUMDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
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Date.............. ........
13
,40RTPI TOWN OF NORTH ANDOVER
to
PERMIT AdR GAS INSTALLATION
CH
This certifies that ... /
...............
.
has permission for gas installation . . .,",/ - /
.........................
in the buildings of ...............................
at ...... x . ............... North Andover, Mass.
Fee./.. Lic. No... ..........................
GAS INSPECTOR
WHITE: Applicant—' CANARY: Building Dept. PINK: Treasurer GOLD: File
V
MAS�ACHUSETTS UNIFORM APPLICATION IrOfj PERMIT TO DO GASFITTIN'G
(Print or Type)
NORTH ANDOVER Mass. Date 3
Ouilding Location A7 156-19coiv /i�-// Permit #
5 L VO,
t1, 7 & Owners Name /MVI?t 130 /.Z K C -
Plans Submitted /V 0
New 77 Renovation Replacement
FIXTUPE:S
(Print or Type) Check one: Certificate
Installing Company Name [--] Corp.
Address ;Z,?X Partner._
F-1 Firm/Co.
Business Telephone: Ot ?,�--2-7 2-1�
Name of Licensed Plumber or Gas Fitter Ti
Insuranc(- Coverag Indicate the type of i-isurance coverage by checking the
appropriate box:
Liability insurance policy F6-,-]- Other type of indemnity F� Bond F1
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 1-1 Agent 0
I hereby certify that all of the dc(Ads and information I haye submitted (or entered) in above application are true and accurate to the best of mY
knowledge and that stl plumbing work and LnstAlla(iorts performed under rt(mit issLed fo: this application will-bc In compKance with 911 PCItillent
provisions of the ?4isachusetts State Cas Code and Chapter 142 of the Central Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:-
-
lumber
— Gasfitter Signature of Licensed
— Master Plumber or Gasfitter
— Zourneyrnan ')02-39
Lfcense Number
van
W4"b 21te1W
(Print or Type) Check one: Certificate
Installing Company Name [--] Corp.
Address ;Z,?X Partner._
F-1 Firm/Co.
Business Telephone: Ot ?,�--2-7 2-1�
Name of Licensed Plumber or Gas Fitter Ti
Insuranc(- Coverag Indicate the type of i-isurance coverage by checking the
appropriate box:
Liability insurance policy F6-,-]- Other type of indemnity F� Bond F1
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner 1-1 Agent 0
I hereby certify that all of the dc(Ads and information I haye submitted (or entered) in above application are true and accurate to the best of mY
knowledge and that stl plumbing work and LnstAlla(iorts performed under rt(mit issLed fo: this application will-bc In compKance with 911 PCItillent
provisions of the ?4isachusetts State Cas Code and Chapter 142 of the Central Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICENSE:-
-
lumber
— Gasfitter Signature of Licensed
— Master Plumber or Gasfitter
— Zourneyrnan ')02-39
Lfcense Number
'JltvL1t-VVl 14-10 kA�i 161 09!e 10JU CASSIDY ASSOCIATES
[A 001
CERTIFICATE OF LIABILITY INSURANCE
OATNE
.AC
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN AEDUCED BY PAID CLAIMS-
INSR I
LTR
THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
CASSIDY ASSOCIATES INS AGENCY
234 HUMPHREY STREET
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICA'M ODES, NOT AMEND, FITEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
SWAMPSCOTT, MA 01907,013
7814984m
moom
LEBLANC, ROGER S
MPSWICH ROAD
muFARk-CENTRAL MUTUAL INSURANCE COMPANY
INVJAER 6:
INSUFa P�
80)(FORDJAA 01921
RISURS D:
X C0104ERCIAL 13ENSIAL LIABILly
—1 0-04 MADE 7x OCCUR
wSUm El I
I
194111�.TT6w-
THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED M THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIIHSTANOING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT Oft OTHER DOCUMENT WITH RE$PECT TO WHICH THIS CERTIRCATE MAY BE ISSUED OR
MAY PER`rAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCIJJSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN AEDUCED BY PAID CLAIMS-
INSR I
LTR
TYPE OF mma"CE
POLICY Kum=
POLrQY CFFMTFVE
PID= WIPIRATION
021220
Lwm
OC"RONCE s 5001.000
A
GEREPAL UAfXITY
ROP7948641
VJ22101
-EACH
nw- nmmm (my "e fh) s AD%=
X C0104ERCIAL 13ENSIAL LIABILly
—1 0-04 MADE 7x OCCUR
mm W o" gm potwn) s 5.m
PERSONAL & ADY INJURY S
GENERAL AaGREGATE s 1,00AN
PRODUM - COW10P AM
CEN'L AGGREGATE LIMTF AMES PER
X] Poxy F-1 PERCOT- Loc
AUTONOBU
LIABM
ANY AM
00MRINFID SINGLE LIMFr
(Ea soc"ll
BODILY Wum
(Per pawn)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY "Ry s
(Par mmidefto
Hm AUTOS
NON -OWNED AUTOS
PROPEIM DAIAAQE
(Por a=16pni)
CARAGE UABILINY
AUTO ONLY - FA ACCIDENT S
OTHER THAN EA ACC $
AW AUTO
AUTO ONILY: AGG. S
IOU= LLhou"
EACH OCCURRENCE S
OCCUR 7 CLAVAS MAU
AGGREMIE 3
DEDUCROLE
WORKEU COMPgNSATM AND
5 T 71
nowyaw ukalm
EL RACH AMD&Y
EL. DISEASE - EA EWLOYBE
E.L. DISEASE - POLICY LVAIT
O==MN OF OPI[RATIONSMOCATION&VEHICLE&OMWPONS ADDED BY ENDORSeMONTISPECIAL PROVWONS
(3 4p cL c a, 1-4 '1 13 1 Led.
c, rL 7 A ot v c ot 1-7 A
fNSUPJM LErfER:,
NORTH ANDOVER BUILDING INSPECTOR
(9715) sm-no
AC43RO 2&S (719A
PMLD ANY OF TK ABOVE OMEM POLIIM BE CANCELLED DOM 7HE MIPIRATM
CATR WEREIDIF, M e9UINQ INSURIM WILL ENDEAVOR TO MAL 30 13AYS WRlTrEN
NDTICF TO THE CERIrRCAYE HOLDER IIAMIM TO THE LEFT. OW FAILURE TO 00 30 $"ALL
IIAPGM NO 0KICATION OR La8Vff'OF ANY IWO UPON TK INSURM IM AGEM OR
a ACOWCORPORATION 19M
N2 3023
0
0
Date.,/ 7y
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
S
....... ...................
This cer ifies that 4-�� .......
has permission to perform * .3
plumbing in the buildings Of .
.................................
at -,,-0',2 ...... North Andover, Mass.
—Irv,
Fee..36. Lic. Nd�'?!Vj �' .. ..... . ".
PLUMBING INSPECTOR
01/21/99 14:40 3 1 100 PA17D
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
(Print'"or Type)' Check one: Certificate
installing Company Name 41 Ale 7alt
Corp.
Address 2-397, Lh=V�-Wd 07 Partner.
FirmlCo.
&77/vi-w
Business Telephone q7,:� 131s -
Name of Licensed Plumber: \A1,Y11*xy 7,
Insurance Coverag Indicate the typ2 of insurance coverage by checking the
appropriate box:
Liability insurance policy E�—�Lher type of indemnity 0 Bond Li
Insurance Waiver: 1, the undersigned, have been made aware -that the licensee Qf
this application does not have any one of the above three insurince coveragm
Signature of owneriagent. of property Owne.r Agent \
604 Ike 14"t -��694 to " W64 4d of
tkcxbr ccsl�fy 64 -al 411 a( doc dclails and infainsalian I havc submil 1cd (a( cnwcd) in atus-C xpl4i=
kisawksigg &ad " all Plumbing W ask SCA insulta6atu licifai mcd unact rcotiti( ittuca (at this arpik-uia4 69 FqO"" PW1
Vibig . "Of LbAbL&L&"umtljSUtc rluutbiagCQdc &ad G-Aptci 142 of (licCcarA &I LAwL. L 1 1 44
By
Title
city/Town:
A Dnonl/Pr) 7nF:;;ir;: ij-qF n?4t Yi
Signature of Licensed Pl=bCZ7
Type of Plumbing License
';L 0 2- 3
License Number Master [3��Journeyz&4